A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and restricting their options for obtaining these drugs. The findings come after a comprehensive 32-month investigation by the committee, which precedes an upcoming hearing involving executives from the nation’s largest PBM firms.
PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating prices with pharmaceutical companies on behalf of health plans. They also determine the out-of-pocket costs for patients. The three largest PBMs in the nation—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—handle about 80% of prescriptions in the United States.
The committee’s report highlighted that PBMs are promoting lists of preferred medications that prioritize higher-priced brand-name drugs over more affordable alternatives. For instance, the report referenced correspondence from Cigna suggesting that patients avoid cheaper substitutes for Humira, a treatment for autoimmune conditions that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, the committee’s investigation found that Express Scripts informed patients that filling prescriptions at local pharmacies would incur higher costs than purchasing a three-month supply through its affiliated mail-order service. This practice restricts patients’ choices in selecting a pharmacy.
A parallel report published by the U.S. Federal Trade Commission earlier this month also addressed similar concerns, indicating that increasing consolidation in the PBM sector has left the top six PBMs controlling nearly 95% of filled prescriptions across the country. The FTC expressed alarm over the significant influence these leading PBMs hold over Americans’ access to and affordability of prescription medications, warning that conflicts of interest may arise when vertically integrated PBMs favor their own affiliated businesses, harming independent pharmacies and elevating drug prices.
FTC Chair Lina M. Khan emphasized that these findings reveal that intermediaries are charging patients excessive amounts for cancer treatments, contributing an estimated additional billion dollars in revenue.