A recent report from the House Committee on Oversight and Accountability highlights concerns that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. The findings were published by the Wall Street Journal and stem from a 32-month investigation conducted by the committee, which is preparing for a hearing involving executives from the nation’s largest PBMs.
PBMs act as intermediaries for prescription drug plans offered by health insurers, negotiating pricing with pharmaceutical firms and determining patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for around 80% of prescriptions filled nationwide.
The committee’s report indicates that these PBMs have developed preferred drug lists that often include higher-cost brand-name medications rather than less expensive alternatives. For instance, internal communications from Cigna were cited, revealing discouragement against using lower-cost options for Humira, an autoimmune treatment priced at $90,000 annually, despite the availability of a biosimilar at half the cost.
Additionally, the report noted Express Scripts informing patients that filling a prescription at their local pharmacy could result in higher costs than obtaining a three-month supply through their affiliated mail-order service, thus restricting patient choice in selecting pharmacies.
A similar report released by the U.S. Federal Trade Commission (FTC) earlier this month confirmed concerns over the concentrated power of PBMs, noting that the six largest companies manage nearly 95% of all prescriptions in the U.S. The FTC expressed alarm over the significant influence these businesses hold over access to affordable medications, highlighting potential conflicts of interest that could arise from their integrated operations. FTC Chair Lina M. Khan stated that these middlemen are effectively overcharging patients for critical cancer drugs, generating additional revenue exceeding $1 billion.