A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients toward more expensive medications while restricting their pharmacy options. This report follows a 32-month investigation preceding a committee hearing featuring executives from the top PBMs in the country.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating costs with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—account for roughly 80% of all prescriptions filled in the U.S.
The committee’s findings indicate that these PBMs have established preferred drug lists favoring costly brand-name medications over more affordable alternatives. For instance, emails from Cigna staff highlighted discouragement against opting for less expensive substitutes for Humira, a treatment for arthritis with a price tag of $90,000 annually, even when biosimilars were available at half that cost.
Additionally, the report points out that Express Scripts informed patients that obtaining prescriptions through their affiliated mail-order service would be cheaper than filling them at their local pharmacies, effectively restricting patient pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) released a similar report noting that rising vertical integration among major PBMs gives them control over nearly 95% of all prescriptions in the U.S. This consolidation has raised concerns regarding their influence over patients’ access to affordable medications. The FTC highlighted that leading PBMs have significant power, leading to potential conflicts of interest that could disadvantage independent pharmacies.
FTC Chair Lina M. Khan emphasized that these middlemen are contributing to increased costs for patients, particularly for cancer medications, generating over $1 billion in additional revenue.