A recent report from the House Committee on Oversight and Accountability highlights concerns regarding pharmacy-benefit managers (PBMs), which are reportedly steering patients toward more costly medications and restricting their pharmacy options. The findings are based on a 32-month investigation and precede an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with drug manufacturers and determining patient out-of-pocket expenses. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—handle about 80% of prescriptions nationwide.
According to the report, these managers tend to promote lists of preferred medications that include pricier brand-name drugs while sidelining more affordable options. An instance cited involves internal communications at Cigna that discouraged using less expensive alternatives to the arthritis drug Humira, which at the time cost $90,000 annually, despite the availability of a biosimilar for half that price.
The committee also discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply from its mail-order service, effectively limiting patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that consolidation among major PBMs has allowed the six largest firms to oversee nearly 95% of all U.S. prescriptions. The FTC emphasized that this concentration of power hinders Americans’ access to affordable medications and creates conflicts of interest that may harm independent pharmacies, ultimately driving up drug prices.
FTC Chair Lina M. Khan stated that the findings reveal that these intermediaries are effectively “overcharging patients for cancer drugs,” resulting in excess revenue exceeding $1 billion.