A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy options. This report, which emerges after a 32-month investigation, coincides with a forthcoming hearing featuring executives from the major PBM companies.
PBMs act as intermediaries for health insurers, managing prescription drug plans and negotiating prices on behalf of health plans. They also determine patients’ out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx (a part of UnitedHealth Group), and CVS Health’s Caremark—handle about 80% of prescriptions in the country.
According to the committee’s findings, these PBMs have developed preferred drug lists that prioritize high-priced brand-name medications over cheaper generics. For instance, the report highlights internal emails from Cigna, which discouraged the use of less expensive alternatives to the autoimmune drug Humira, priced at $90,000 annually when cheaper biosimilars were available for approximately half that cost.
The committee further noted that Express Scripts informed patients they would pay more for prescriptions filled at local pharmacies compared to getting a three-month supply from its affiliated mail-order service. This practice limits patients’ pharmacy choices.
In a related report published earlier this month, the U.S. Federal Trade Commission (FTC) indicated that the six largest PBMs manage nearly 95% of prescriptions filled in the U.S., raising concerns about their market dominance. The FTC described the significant influence of PBMs on Americans’ access to and affordability of prescription medications, suggesting that their practices result in conflicts of interest that may disadvantage independent pharmacies and drive up drug costs.
FTC Chair Lina M. Khan remarked that these findings reveal how PBMs are overcharging patients, particularly for cancer treatments, generating additional revenue exceeding $1 billion in the process.