A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. This report follows a 32-month investigation ahead of a hearing that involved executives from the country’s largest PBMs.
PBMs serve as third-party administrators for prescription drug plans provided by health insurers, negotiating costs with pharmaceutical companies and establishing out-of-pocket expenses for patients. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—manage around 80% of all prescriptions.
According to the report, PBMs are creating preferred drug lists favoring higher-cost brand-name medications over less expensive alternatives. For instance, the report references internal communications from Cigna that discouraged selecting cheaper options for Humira, a treatment that previously cost $90,000 annually, despite available biosimilars priced at half that amount.
The committee discovered that Express Scripts advised patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby restricting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that the largest six PBMs manage nearly 95% of prescriptions filled in the country. The FTC’s findings raise concerns about the substantial influence these PBMs have on Americans’ access to affordable prescription medications, indicating that their integrated business models lead to conflicts of interest that could disadvantage unaffiliated pharmacies and drive up drug costs.
FTC Chair Lina M. Khan pointed out that these “middlemen” are reportedly overcharging patients for cancer medications, generating additional revenue exceeding $1 billion.