A recent report from the House Committee on Oversight and Accountability highlights how pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy choices. This report follows a 32-month investigation and precedes a hearing featuring executives from the largest PBMs in the country, according to the Wall Street Journal.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx by UnitedHealth Group, and Caremark owned by CVS Health—manage about 80% of prescriptions in the United States.
The committee’s findings indicate that PBMs maintain lists of preferred medications that often highlight costlier brand-name drugs rather than more affordable alternatives. For instance, emails revealed that Cigna staff discouraged the use of less expensive options for Humira, an arthritis treatment that was priced at $90,000 annually, even though a biosimilar was available for about half that cost.
Additionally, the inquiry uncovered that Express Scripts informed patients that they would face higher costs when filling prescriptions at local pharmacies compared to the lower prices available through its affiliated mail-order service. This practice restricts patients’ choices regarding which pharmacy to use.
In a related development, the U.S. Federal Trade Commission (FTC) released a report earlier this month noting that the six largest PBMs now oversee nearly 95% of all prescriptions filled in the U.S. The FTC’s interim report expressed concern over the significant power held by leading PBMs, stating that this concentration complicates Americans’ access to affordable medications.
FTC Chair Lina M. Khan pointed out that these intermediaries are “overcharging patients for cancer drugs,” resulting in more than $1 billion in extra revenue.