A recent report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications and restricting their options for obtaining prescriptions. This report follows a 32-month investigation and precedes a hearing featuring executives from the country’s leading PBMs.
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 nation’s three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—account for about 80% of prescriptions filled in the U.S.
The committee’s findings indicate that these PBMs have developed lists of preferred drugs that prioritize higher-priced brand-name medications over more affordable alternatives. An example highlighted in the report involves communications from Cigna’s staff that discouraged the use of less expensive substitutes for Humira, a treatment for arthritis and other autoimmune conditions, which costs around $90,000 annually. In contrast, at least one biosimilar version of the drug is available for half that price.
Additionally, the committee noted that Express Scripts informed patients they would incur higher costs by filling a prescription at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice has restricted patients’ choice of pharmacies.
This month, the U.S. Federal Trade Commission (FTC) also released a report, indicating that increasing consolidation has allowed the six largest PBMs to control nearly 95% of all prescriptions in the United States. The FTC expressed concerns over the significant influence these PBMs wield over Americans’ access to affordable medications, highlighting that their practices may create conflicts of interest that negatively impact independent pharmacies and elevate prescription drug prices.
FTC Chair Lina M. Khan emphasized that the findings suggest these intermediaries are effectively “overcharging patients for cancer drugs,” generating additional revenue exceeding $1 billion in the process.