A recent report from the House Committee on Oversight and Accountability claims that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications while restricting their access to cheaper options. This follows a 32-month investigation and comes ahead of a forthcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as third-party administrators for prescription drug plans under health insurers, negotiating prices for medications and determining out-of-pocket costs for patients. The three dominant PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control about 80% of U.S. prescriptions.
The committee’s findings indicate that PBMs often favor higher-priced brand-name drugs on their preferred drug lists, sidelining cost-effective alternatives. For instance, emails from Cigna revealed resistance to recommending cheaper substitutes for Humira, a medication for arthritis and autoimmune disorders, which costs around $90,000 annually, despite the presence of a biosimilar available for half that price.
Moreover, Express Scripts reportedly informed patients that filling prescriptions at local pharmacies would be more costly than obtaining a three-month supply through its affiliated mail-order service, thereby restricting patient choices regarding pharmacy options.
Additionally, a recent report from the U.S. Federal Trade Commission (FTC) echoed similar concerns, highlighting that increasing consolidation has allowed the top six PBMs to manage nearly 95% of all prescriptions in the United States. The FTC stated that leading PBMs exert considerable influence over Americans’ access to affordable medications, often favoring affiliated businesses and potentially disadvantaging independent pharmacies.
FTC Chair Lina M. Khan pointed out the troubling trends, stating that these intermediaries are “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for PBMs.