A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while imposing restrictions on their pharmacy choices.
The committee’s findings, highlighted in the Wall Street Journal, come after a 32-month investigation leading up to a hearing involving executives from the largest PBMs in the U.S.
PBMs act as intermediaries in prescription drug plans for health insurers, negotiating drug prices with pharmaceutical companies and determining patients’ out-of-pocket expenses. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control about 80% of U.S. prescriptions.
According to the report, PBMs have developed preferred drug lists that favor higher-priced brand-name medications over more affordable options. One example included emails from Cigna personnel discouraging the use of cheaper alternatives to Humira, an arthritis treatment that costs approximately $90,000 annually, despite the availability of a biosimilar for about half that price.
The committee also noted that Express Scripts informed patients that they would incur higher costs if they filled prescriptions at local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service, effectively limiting patients’ pharmacy options.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report indicating that increasing integration and concentration among PBMs has allowed the six largest companies to manage nearly 95% of all prescriptions in the United States.
The FTC expressed concern, stating that the dominant PBMs hold substantial influence over patients’ access to and affordability of prescription medications. The report highlighted that these integrated entities may prioritize their own affiliated businesses, leading to conflicts of interest that could disadvantage independent pharmacies and elevate drug prices.
FTC Chair Lina M. Khan emphasized that the findings indicate these intermediaries are “overcharging patients for cancer drugs,” generating more than $1 billion in additional revenue for the PBMs.