A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications while restricting their access to cheaper options. This report follows a 32-month investigation and comes just before a hearing featuring top executives from the largest PBMs.
PBMs serve as intermediaries for health insurers’ prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three biggest PBMs in the U.S.—Express Scripts, OptumRx (UnitedHealth Group), and Caremark (CVS Health)—control around 80% of the nation’s prescriptions.
The committee’s findings indicate that PBMs favor pricier brand-name drugs over more affordable alternatives on their preferred drug lists. For instance, the report includes emails from Cigna employees advising against lower-cost options for Humira, a medication for arthritis and other autoimmune disorders that was priced at $90,000 annually, despite the availability of a biosimilar for half that amount.
The investigation also revealed that Express Scripts informed patients they would incur higher costs when filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, thereby restricting patients’ pharmacy choices.
This insight aligns with a recent interim report from the U.S. Federal Trade Commission (FTC), which highlighted that the largest six PBMs manage nearly 95% of U.S. prescriptions due to increased vertical integration and market concentration.
The FTC’s findings raise concerns about the significant influence PBMs have over Americans’ access to affordable medications. The report points to potential conflicts of interest, as integrated PBMs may prioritize their own affiliated businesses, disadvantaging independent pharmacies and driving up drug prices. FTC Chair Lina M. Khan noted that these intermediaries have been found to “overcharge patients for cancer drugs,” generating over $1 billion in additional revenue.