A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients towards more expensive medications and restricting their pharmacy options. This finding emerged after a 32-month investigation, which included a hearing featuring executives from the largest PBM companies.
PBMs serve as intermediaries for prescription drug plans, negotiating prices with pharmaceutical companies on behalf of health insurers and determining out-of-pocket costs for patients. Three major players—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of prescriptions in the United States.
The committee’s report indicates that PBMs are curating preferred drug lists that favor higher-priced brand-name drugs over their more affordable counterparts. An example highlighted in the report involves Cigna, which discouraged staff from recommending cheaper alternatives to Humira, an autoimmune treatment costing approximately $90,000 annually, despite the availability of a biosimilar at half the price.
The committee also noted that Express Scripts informed patients they would face higher costs if they filled prescriptions at local pharmacies compared to receiving a three-month supply through its mail-order service, thereby limiting pharmacy choices.
Compounding these concerns, the U.S. Federal Trade Commission (FTC) released a similar report, stating that heightened vertical integration among PBMs has resulted in the six largest firms managing nearly 95% of all prescriptions filled in the country. The FTC highlighted this consolidation as problematic, granting leading PBMs substantial control over patients’ access to affordable medications. The findings also pointed to potential conflicts of interest, as integrated PBMs may favor their affiliate businesses, which could disadvantage independent pharmacies and drive up drug costs for consumers.
FTC Chair Lina M. Khan noted that these middlemen are overcharging patients for cancer medications, accumulating excess revenues exceeding $1 billion.