A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients towards pricier medications while also restricting their pharmacy options. This report, which is based on a 32-month investigation, precedes a hearing featuring executives from some of the largest PBMs in the U.S.
PBMs function as intermediary administrators of prescription drug plans for health insurers, negotiating the costs of medications with pharmaceutical companies and determining out-of-pocket expenses for patients. The three largest PBMs in the nation—Express Scripts, OptumRx (a division of UnitedHealth Group), and Caremark (a CVS Health company)—control nearly 80% of prescriptions filled across the country.
The committee’s findings indicate that PBMs maintain preferred drug lists that favor higher-priced brand-name drugs over more affordable alternatives. For instance, the report highlights communications from Cigna employees discouraging the use of less expensive substitutes for Humira, a medication for arthritis and other autoimmune disorders that cost up to $90,000 annually, while a biosimilar option was available for half that price.
Additionally, the investigation revealed that Express Scripts informed patients that they would incur higher costs by filling prescriptions at their local pharmacies compared to obtaining a three-month supply from its affiliated mail-order service. This practice appears to restrict patients’ freedom to choose their pharmacies.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report noting that the six largest PBMs account for nearly 95% of all prescriptions dispensed in the U.S. The FTC’s findings are alarming, suggesting that major PBMs hold considerable influence over Americans’ access to affordable medications, and that their business practices may create conflicts of interest that disadvantage independent pharmacies while raising drug prices.
FTC Chair Lina M. Khan emphasized that these middlemen are reportedly overcharging patients for cancer medications, generating over $1 billion in additional revenue.