A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more costly medications while restricting their pharmacy choices. This report follows a 32-month investigation by the committee in preparation for a hearing featuring executives from major PBMs.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs in the U.S.—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (owned by CVS Health)—control roughly 80% of prescriptions filled nationwide.
According to the report, PBMs have developed preferred drug lists favoring higher-priced brand-name medications over more affordable alternatives. An example highlighted involves Cigna employees discouraging the use of lower-cost alternatives to Humira, a medication for arthritis and autoimmune conditions, which was priced at $90,000 annually, despite the availability of a biosimilar option at half the cost.
The findings also indicated that Express Scripts informed patients they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through their affiliated mail-order service, thereby limiting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, noting that consolidation within the market has empowered the six largest PBMs to oversee nearly 95% of prescriptions filled in the country. The FTC expressed concern over this trend, highlighting that leading PBMs possess significant control over Americans’ access to affordable prescription medications. This dynamic fosters conflicts of interest, as vertically integrated PBMs may favor their affiliated businesses, potentially disadvantaging independent pharmacies and driving up drug costs.
FTC Chair Lina M. Khan remarked that these middlemen are excessively charging patients for cancer medications, yielding them over $1 billion in additional revenue.