A new report from the House Committee on Oversight and Accountability indicates that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting access to lower-cost alternatives. This finding follows an extensive 32-month investigation and precedes a hearing on PBMs with executives from the largest firms in attendance.
PBMs act as intermediaries for health insurers in managing prescription drug plans, negotiating prices with pharmaceutical companies and determining patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (part of CVS Health)—control about 80% of prescriptions in the United States.
The committee’s investigation revealed that PBMs often promote lists of preferred drugs that feature pricier branded medications rather than cheaper options. One notable example included internal communications from Cigna that discouraged using less expensive alternatives to Humira, a drug for arthritis and other autoimmune disorders priced at $90,000 annually, despite the availability of a biosimilar that cost approximately half that amount.
Additionally, the report highlighted that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to ordering a three-month supply through its mail-order service. This practice limits patient choice regarding where to obtain their medications.
A recent report by the U.S. Federal Trade Commission echoed similar concerns, stating that the six largest PBMs manage nearly 95% of all prescriptions in the country. The FTC noted that these PBMs hold substantial influence over Americans’ access to affordable medications and may favor their own businesses, resulting in conflicts of interest that can disadvantage independent pharmacies and elevate drug costs.
FTC Chair Lina M. Khan emphasized that these findings indicate that PBMs are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue.