A recent report by the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications and are restricting access to certain pharmacies. This investigation, which spanned 32 months, precedes a hearing involving executives from the nation’s leading PBMs.
PBMs act as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three major PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of the nation’s prescriptions.
The committee’s findings suggest that PBMs have developed lists of preferred medications that primarily feature more expensive brand-name drugs rather than less costly alternatives. For instance, the report mentioned emails from Cigna staff advising against the use of biosimilars for Humira, an arthritis medication that cost $90,000 annually, despite a similar treatment being available for half that price.
Additionally, the report indicated that Express Scripts informed patients that they would incur higher costs by using their local pharmacy instead of opting for a three-month supply through their mail-order service, thereby constraining patient choice.
A similar report released by the U.S. Federal Trade Commission (FTC) highlights that the largest six PBMs now oversee nearly 95% of all prescriptions filled in the country. The FTC expressed concern over the growing power of these PBMs, stating that their influence may limit patients’ access to affordable medications and create conflicts of interest, particularly as PBMs seem to favor their own affiliated businesses.
FTC Chair Lina M. Khan noted that evidence suggests that these intermediaries are overcharging patients for essential drugs, generating excess revenue exceeding $1 billion.