A new report from the House Committee on Oversight and Accountability highlights how pharmacy-benefit managers (PBMs) are guiding patients toward more costly medications while restricting their pharmacy choices. This report follows a 32-month investigation ahead of an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries for prescription drug plans on behalf of health insurers, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—together manage around 80% of U.S. prescriptions.
The committee’s findings reveal that PBMs have developed preferred drug lists that favor higher-priced brand-name medications over cheaper alternatives. For instance, emails from Cigna employees were cited in the report discouraging the use of lower-cost alternatives to Humira, a medication for arthritis and other autoimmune diseases, which had an annual cost of $90,000 when cheaper biosimilars were available.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, effectively limiting patient options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the largest six PBMs now control nearly 95% of all prescriptions filled in the U.S. The FTC expressed concern about the significant power these PBMs wield over patients’ access to affordable medications. The report suggests that the structure of vertically integrated PBMs may create conflicts of interest, disadvantaging unaffiliated pharmacies and contributing to higher drug prices.
FTC Chair Lina M. Khan stated that the findings reveal how these intermediaries may be “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.