A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their options for obtaining these drugs. This report follows a detailed, 32-month investigation and comes ahead of a hearing featuring executives from the largest PBMs in the country.
PBMs act as intermediaries between health insurers and pharmaceutical companies, negotiating drug prices and setting patients’ out-of-pocket costs. The trio of largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—together manage about 80% of U.S. prescriptions.
Key findings of the committee’s report indicate that these managers often curate lists of preferred medications that favor more costly brand-name drugs over more affordable alternatives. For instance, emails from Cigna employees in the report discouraged the use of lower-priced alternatives to Humira, a drug priced at $90,000 annually for arthritis and autoimmune conditions, despite the availability of a biosimilar at half that cost.
Additionally, the committee discovered that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-service pharmacy. This practice effectively limits patient choices regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report highlighting the growing power of the top six PBMs, which control nearly 95% of all prescriptions filled in the country. The FTC’s findings are concerning, indicating that these PBMs wield significant influence over Americans’ access to and affordability of prescription drugs. This vertical integration raises potential conflicts of interest, as these PBMs may prefer their own affiliated businesses, potentially disadvantaging independent pharmacies and driving up costs for medications.
FTC Chair Lina M. Khan emphasized that the conclusions point to these middlemen overcharging patients for cancer treatments, generating over $1 billion in additional revenue.