A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their access to certain pharmacies. The investigation, which lasted 32 months, precedes a hearing involving executives from the largest PBMs in the country.
PBMs act as intermediaries for health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control about 80% of prescriptions in the U.S.
According to the report, PBMs have established preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. An example cited includes emails from Cigna employees who advised against using cheaper substitutes for Humira, which at the time cost around $90,000 annually, while a biosimilar was available for about half that price.
The findings also highlighted that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its mail-order service, thereby limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the largest six PBMs manage nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the significant power these PBMs hold over Americans’ access to affordable medications, suggesting that their integration with pharmacies leads to conflicts of interest that could disadvantage independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan noted that these middlemen are effectively overcharging patients for cancer treatments, resulting in additional profits exceeding $1 billion.