A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy options. The findings come after a 32-month investigation, coinciding with an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers and negotiate prices with pharmaceutical companies. They also determine the out-of-pocket costs patients incur. The three largest PBMs in the United States—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—control around 80% of prescriptions filled nationwide.
The committee’s investigation indicated that PBMs often construct lists of preferred drugs that prioritize more expensive brand-name products over cheaper alternatives. For instance, it highlighted communications from Cigna’s staff that discouraged seeking cost-effective substitutes for Humira, an arthritis treatment with an annual price tag of $90,000 at that time, despite the availability of a biosimilar option at half the cost.
Furthermore, the report noted that Express Scripts recommended that patients obtain a three-month supply from its affiliated mail-order pharmacy, claiming they would incur lower costs than filling their prescriptions at local pharmacies. This practice effectively limited patient choice regarding where to fill their prescriptions.
Earlier this month, the U.S. Federal Trade Commission (FTC) released a similar report, stating that growing vertical integration has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the U.S. The FTC described this trend as troubling, noting that dominant PBMs wield significant influence over patients’ access to affordable medication. It warned that vertically integrated PBMs might favor their affiliated businesses, create conflicts of interest, and contribute to escalating drug costs.
FTC Chair Lina M. Khan emphasized that the report suggested these middlemen are charging patients excessively for critical medications, leading to over $1 billion in additional revenue.