A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are steering patients towards pricier medications while restricting their pharmacy options. This findings follow a 32-month investigation ahead of an upcoming hearing featuring executives from the nation’s largest PBMs.
PBMs serve as third-party administrators for health insurers’ prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—together manage around 80% of prescriptions in the United States.
The report indicates that these PBMs have developed preferred drug lists that prioritize costlier brand-name medications over more affordable alternatives. For instance, correspondence from Cigna staff is cited, illustrating discouragement of cheaper substitutes for Humira, a drug for arthritis and autoimmune conditions, which at the time had an annual cost of $90,000, despite a biosimilar option available for half that price.
Furthermore, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service. This practice effectively limits patient choices regarding where they can fill prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting that the six largest PBMs now control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern about the significant influence these PBMs wield over patients’ access to affordable medications. They noted that the vertically integrated nature of these companies creates conflicts of interest, potentially disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan emphasized that these findings indicate that these intermediaries are overcharging patients for cancer drugs, generating over $1 billion in excess revenue.