A recent report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients towards higher-priced medications while curtailing their pharmacy options. This finding follows a 32-month investigation and precedes a hearing with leaders from major PBM companies.
PBMs act as intermediaries in prescription drug plans, negotiating prices with pharmaceutical firms and determining patient out-of-pocket expenses. The three largest PBMs in the U.S.—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control around 80% of the nation’s prescriptions.
The committee’s investigation revealed that PBMs maintain lists of preferred medications that prominently feature higher-cost brand-name drugs rather than economical alternatives. For instance, internal communications from Cigna discouraged the use of less expensive options for Humira, a drug for arthritis costing approximately $90,000 annually, despite the availability of a biosimilar at about half the cost.
Additionally, the committee noted that Express Scripts informed patients that filling a prescription at a local pharmacy would be costlier than ordering a larger quantity through its affiliated mail-order service, thereby restricting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that the six largest PBMs manage nearly 95% of all prescriptions filled in the country. The FTC’s findings suggest that these PBMs wield significant influence over access to and affordability of prescription medications for Americans. The report raises concerns about conflicts of interest, as vertically integrated PBMs may preferentially support their own businesses, disadvantaging independent pharmacies and resulting in higher drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are “overcharging patients for cancer drugs,” contributing over $1 billion in additional revenue.