A recent report from the House Committee on Oversight and Accountability highlights concerns about pharmacy-benefit managers (PBMs), suggesting they are directing patients towards more expensive medications while restricting their pharmacy options.
The committee’s investigation, which spanned 32 months, was released in advance of a hearing featuring executives from the largest PBM companies in the nation. PBMs serve as intermediaries for health insurers, negotiating prices with pharmaceutical firms and determining patient out-of-pocket costs. The three dominant PBMs—Express Scripts, OptumRx from UnitedHealth Group, and CVS Health’s Caremark—account for around 80% of U.S. prescriptions.
The report pointed out that these PBMs often compile lists of preferred medications that prioritize higher-priced brand-name drugs over less expensive alternatives. An example cited in the report refers to emails from Cigna staff that actively discouraged using more affordable substitutes for Humira, an arthritis medication that costs approximately $90,000 annually, despite the availability of biosimilars at half that price.
Additionally, the committee found that Express Scripts advised patients that filling prescriptions at local pharmacies would result in higher costs compared to obtaining a three-month supply through its mail-order service. This practice effectively restricts patient choices regarding pharmacy selection.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that the top six PBMs control nearly 95% of all prescriptions filled in the United States. The FTC expressed concern over the considerable influence PBMs wield over Americans’ access to and affordability of prescription medications, highlighting that vertically integrated PBMs might favor their own businesses at the expense of unaffiliated pharmacies, potentially raising drug costs.
FTC Chair Lina M. Khan stated that these findings indicate PBMs may be overcharging patients for critical medications like cancer drugs, generating more than $1 billion in additional revenue.