A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are pushing patients toward costlier medications and restricting their access to certain pharmacies. The findings stem from a 32-month investigation and precede a hearing featuring executives from the largest PBMs in the nation.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage nearly 80% of prescriptions filled in the United States.
The committee’s findings indicate that these PBMs have established preferred drug lists that often include pricier brand-name medications while sidelining more affordable alternatives. The report highlights internal communications from Cigna, which suggested steering patients away from cheaper substitutes for Humira, an arthritis treatment that was priced at $90,000 annually, despite the existence of a biosimilar option available for around half that cost.
Additionally, Express Scripts reportedly informed patients that filling a prescription at their local pharmacy would result in higher costs than purchasing a three-month supply through their mail-order service, effectively restricting patient choice in pharmacy selection.
In a related development, the U.S. Federal Trade Commission recently released a report indicating that increasing consolidation among PBMs has allowed the six largest firms to control nearly 95% of all prescriptions dispensed in the country. The FTC expressed concern that the current power held by leading PBMs hampers Americans’ access to affordable medication, creating conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are leading to increased costs for patients, particularly for cancer medications, generating excess revenue exceeding $1 billion.