A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting access to pharmacies. This report, which followed a 32-month investigation, was presented ahead of a hearing featuring executives from some of the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans, negotiating prices with pharmaceutical companies and setting out-of-pocket costs for patients. The report indicates that the three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—manage around 80% of prescriptions in the U.S.
According to the committee’s findings, PBMs have created preferred drug lists that favor higher-priced brand-name drugs over cheaper generics. For instance, emails from Cigna suggested avoiding less expensive alternatives to Humira, an arthritis treatment with an annual cost of $90,000, despite the availability of a biosimilar at half the price.
Additionally, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice effectively limits patients’ choices for pharmacy services.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report stating that the six largest PBMs control nearly 95% of all prescriptions in the United States. The FTC expressed concern over the significant influence these PBMs hold in patients’ access to affordable medications, suggesting that their vertical integration could result in conflicts of interest that disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted that these intermediaries are “overcharging patients for cancer drugs,” generating excess revenue exceeding $1 billion.