A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients to more expensive medications and restricting their pharmacy options. This finding follows a 32-month investigation by the committee, which was conducted in anticipation of a hearing featuring leaders from the largest PBM companies in the country.
PBMs serve as intermediaries for prescription drug plans tied to health insurance providers. They negotiate prices with drug manufacturers and determine the out-of-pocket costs that patients face. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control approximately 80% of all prescriptions in the U.S.
The committee’s report indicates that these PBMs have developed preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. For instance, it highlights communications from Cigna that suggested avoiding more cost-effective substitutes for Humira, a psoriasis and arthritis medication costing $90,000 annually, even though a biosimilar was available for around half that amount.
Additionally, the report states that Express Scripts informed patients they would pay more for prescriptions filled at their local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patients’ ability to choose their pharmacy.
A similar analysis was released earlier this month by the U.S. Federal Trade Commission, which noted that the growing vertical integration among PBMs has resulted in the top six firms managing nearly 95% of all prescriptions filled in the nation. The FTC described these developments as concerning, highlighting how dominant PBMs undermine patients’ access to affordable medications. It also pointed out potential conflicts of interest arising from vertically integrated PBMs favoring their affiliated businesses, which could disadvantage independent pharmacies and inflate drug costs.
FTC Chair Lina M. Khan commented that these middlemen are “overcharging patients for cancer drugs,” yielding them over $1 billion in additional revenue.