A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their access to these drugs. This investigation was conducted over a period of 32 months and precedes a hearing involving executives from the largest PBMs in the U.S.
PBMs act as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and establishing patients’ out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—control around 80% of U.S. prescriptions.
The report indicates that PBMs have developed preferred drug lists that prioritize higher-priced brand-name medications over less expensive alternatives. For instance, it references internal communications from Cigna that discouraged the use of affordable substitutes for Humira, an arthritis treatment costing approximately $90,000 annually, despite the availability of a biosimilar for half that amount.
Furthermore, the committee discovered that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from their affiliated mail-order service, effectively limiting patient choice in pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission released a similar report indicating that increased vertical integration among larger PBMs has allowed them to manage nearly 95% of all prescriptions in the United States. The FTC expressed concerns over the significant influence these PBMs wield on American access to affordable medication, highlighting that their practices may create conflicts of interest and disadvantage independent pharmacies.
FTC Chair Lina M. Khan noted that these middlemen are reportedly overcharging patients for cancer treatments, resulting in more than $1 billion in additional revenue for PBMs.