A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their choice of pharmacies. The findings come after a 32-month investigation preceding a hearing involving executives from major PBMs.
PBMs function as intermediaries for prescription drug plans offered by health insurers, engaging with pharmaceutical companies to negotiate drug pricing. They also determine patients’ out-of-pocket expenses for medications. The three largest PBMs in the United States—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—are responsible for managing around 80% of prescriptions nationwide.
The committee’s report indicates that PBMs maintain lists of preferred drugs that favor higher-priced brand-name medications over more affordable alternatives. It highlights communications from Cigna that discouraged the use of cheaper options for Humira, a drug used to treat arthritis and other autoimmune disorders, despite the availability of a biosimilar at half the price.
Additionally, the report mentions that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies instead of through the company’s affiliated mail-order service, thereby limiting pharmacy options for patients.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report stating that the six largest PBMs now account for nearly 95% of all prescriptions filled in the U.S., raising concerns about their substantial influence on access to and affordability of medications. The FTC’s findings suggest that these vertically integrated PBMs may prioritize their own affiliated businesses, creating conflicts of interest that could disadvantage independent pharmacies and escalate drug costs.
FTC Chair Lina M. Khan commented that the findings illustrate how these intermediaries are placing an additional financial burden on patients, especially for cancer medications, leading to over $1 billion in extra revenue for the PBMs.