A new report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their pharmacy options. This report comes after a lengthy 32-month investigation and ahead of a hearing that will feature executives from the largest PBMs in the country.
PBMs operate as third-party administrators for prescription drug plans offered by health insurers. They negotiate prices with drug manufacturers and establish out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for about 80% of prescriptions in the United States.
According to the report, PBMs have created lists of preferred medications that often favor higher-priced brand-name drugs over more affordable alternatives. For instance, internal communications from Cigna highlighted a disincentive for using cheaper options for Humira, an expensive treatment for arthritis and autoimmune conditions, which at one point cost approximately $90,000 annually, despite the availability of biosimilars at half that price.
The committee found evidence that Express Scripts informed patients that they might incur higher costs by using their local pharmacy than if they opted for a three-month supply through its affiliated mail-order service, effectively restricting patients’ pharmacy choices.
Additionally, a recent report from the U.S. Federal Trade Commission (FTC) echoed these findings, stating that the six largest PBMs control nearly 95% of all prescriptions filled in the U.S. This concentration of power raises concerns about patient access to affordable medications, as the FTC noted that these PBMs may favor their own associated businesses, leading to potential conflicts of interest and increased prescription drug prices.
FTC Chair Lina M. Khan remarked that the evidence suggests these intermediaries are overcharging patients for cancer medications, generating over $1 billion in additional revenue.