A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward costlier medications and restricting access to pharmacies. This report follows a 32-month investigation and precedes a hearing featuring executives from the largest PBM companies.
PBMs serve as third-party administrators for drug plans tied to health insurers, negotiating prices with pharmaceutical firms and determining out-of-pocket expenses for patients. The three dominant PBMs in the U.S.—Express Scripts, OptumRx (owned by UnitedHealth Group), and Caremark (part of CVS Health)—control approximately 80% of all prescriptions in the country.
According to the findings, PBMs have established preferred drug lists that often favor higher-priced brand-name drugs over more affordable options. The report highlights communications from Cigna staff that discouraged the use of lower-cost alternatives to Humira, an arthritis treatment priced at $90,000 per year, despite the availability of a biosimilar for about half that amount.
The committee’s investigation also noted that Express Scripts informed patients they would be charged more at local pharmacies compared to obtaining a three-month supply through its mail-order service. This practice limits patient choices regarding where to fill prescriptions.
A parallel report from the U.S. Federal Trade Commission (FTC) stated that heightened vertical integration has led to the six largest PBMs managing nearly 95% of all prescriptions in the U.S. The FTC’s interim findings express concerns about the substantial influence these leading PBMs hold over patients’ access to affordable medications, pointing out potential conflicts of interest that may arise when PBMs favor their own affiliated businesses.
FTC Chair Lina M. Khan emphasized that these middlemen are reportedly overcharging patients for essential drugs, contributing over $1 billion in revenue from cancer medications alone.