A report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their access to certain pharmacies. This report follows a 32-month investigation and comes ahead of a congressional hearing featuring executives from the largest PBMs.
PBMs serve as intermediaries for health insurers, managing prescription drug plans and negotiating prices with pharmaceutical companies. They also determine out-of-pocket costs for patients. The top three PBMs in the U.S.—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—handle around 80% of all prescriptions in the country.
The committee’s investigation uncovered that PBMs often maintain lists of preferred drugs that favor higher-priced brand-name medications over more affordable options. For instance, emails from Cigna’s staff discouraged the use of lower-cost alternatives to Humira, an arthritis treatment costing about $90,000 per year, despite the availability of a biosimilar for approximately half that price.
Additionally, the report indicated that Express Scripts informed patients that they would incur higher costs by obtaining prescriptions from local pharmacies compared to ordering a three-month supply through its own mail-order service, thereby limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that the six largest PBMs manage nearly 95% of prescriptions in the country due to increased industry consolidation. The FTC expressed concern that dominant PBMs wield considerable power over the affordability and accessibility of prescription medications, creating an environment where they may favor their own affiliated businesses and unjustly disadvantage independent pharmacies.
FTC Chair Lina M. Khan highlighted that these middlemen are allegedly overcharging patients for cancer medications, reportedly generating an additional $1 billion in revenue.