A new 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 lower-cost alternatives. This report, which follows a 32-month investigation, precedes a hearing involving executives from the nation’s largest PBMs.
PBMs serve as intermediaries for health insurers, negotiating prices with pharmaceutical companies and determining the out-of-pocket costs for patients. The three largest PBMs in the United States—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—control around 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs have created preferred drug lists that prioritize higher-priced brand-name medications over more affordable options. For instance, emails from Cigna employees discouraged the use of cheaper alternatives to Humira, a drug that costs $90,000 annually, even though a biosimilar was available at half that price.
Additionally, the investigation found that Express Scripts informed patients that filling a prescription at a local pharmacy would be more expensive than obtaining a three-month supply through its affiliated mail-order service, thereby limiting patients’ pharmacy choices.
Earlier this month, the Federal Trade Commission (FTC) published a report that echoed these concerns, noting that as the top six PBMs manage nearly 95% of all prescriptions, they wield considerable influence over drug accessibility and affordability. The FTC warned that this situation creates conflicts of interest and can disadvantage independent pharmacies, leading to increased prescription costs.
FTC Chair Lina M. Khan highlighted that these middlemen are overcharging patients, particularly for cancer treatments, providing them with excess revenue exceeding $1 billion.