A recent report from the House Committee on Oversight and Accountability alleges that pharmacy benefit managers (PBMs) are guiding patients toward pricier medications while restricting their access to them. This report follows a 32-month investigation ahead of an upcoming hearing involving executives from the largest PBMs in the country.
PBMs serve as third-party administrators that manage prescription drug plans for health insurers, negotiating drug prices on their behalf and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control approximately 80% of U.S. prescriptions.
According to the report, PBMs maintain preferred drug lists that often favor high-cost brand-name drugs over lower-cost alternatives. An example cited includes internal communications from Cigna, which discouraged the adoption of more affordable alternatives to Humira, a medication for arthritis and other autoimmune conditions, which has an annual cost of $90,000. A comparable biosimilar was available for about half that price.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order service, thereby limiting patient choice in pharmacy selection.
The U.S. Federal Trade Commission released a similar report earlier this month, indicating that the six largest PBMs together manage nearly 95% of all prescriptions filled in the country. The FTC highlighted concerns regarding the significant influence these leading PBMs have over Americans’ ability to access affordable prescription drugs. The findings suggest that vertically integrated PBMs may prioritize their own affiliated businesses, leading to potential conflicts of interest and increased prescription costs, disadvantaging independent pharmacies.
FTC Chair Lina M. Khan noted that these middlemen are reportedly overcharging patients for cancer medications, generating over $1 billion in additional revenue.