A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications while restricting their pharmacy options. This report, which follows a 32-month investigation, comes ahead of a hearing involving leaders from the largest PBM companies.
PBMs serve as intermediaries for health insurers, negotiating drug prices with pharmaceutical firms and determining out-of-pocket costs for patients. The three largest PBMs in the U.S.—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—account for about 80% of the prescriptions filled in the country.
The committee’s findings indicate that these PBMs often create preferred drug lists that prioritize higher-priced branded medications over more affordable alternatives. For instance, communications from Cigna staff reportedly discouraged the use of cheaper substitutes for Humira, a costly drug for treating arthritis and autoimmune diseases. At that time, Humira’s annual cost was around $90,000, while a biosimilar option was available for significantly less.
Additionally, the report highlights instances where Express Scripts informed patients that they would pay more for prescriptions filled at local pharmacies compared to those obtained through its affiliated mail-order service. This practice limits patients’ choice of pharmacy.
The U.S. Federal Trade Commission (FTC) released a similar report earlier this month, noting that the increasing consolidation among PBMs has allowed the six largest firms to manage nearly 95% of all prescriptions in America. The FTC expressed concerns that dominant PBMs hold considerable power over the accessibility and affordability of prescription medications for Americans. The report also suggested that vertically integrated PBMs may prioritize their own businesses, creating conflicts of interest that could harm independent pharmacies and raise drug prices.
FTC Chair Lina M. Khan emphasized that these findings indicate that PBM middlemen are profiting by overcharging patients for cancer medications, generating over $1 billion in additional revenue.