A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward pricier medications and restricting their pharmacy options. This report follows a 32-month investigation and precedes a hearing with top executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans provided by health insurers, negotiating drug prices with pharmaceutical companies and determining patient out-of-pocket expenses. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control about 80% of prescriptions in the United States.
The committee’s findings indicate that PBMs maintain lists of preferred medications that favor higher-priced brand-name drugs over more affordable substitutes. For instance, internal communications from Cigna referenced in the report suggested avoiding lower-cost alternatives to Humira, a medication for arthritis that was priced at $90,000 annually, despite the availability of a biosimilar at half that cost.
Additionally, Express Scripts reportedly informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply through its affiliated mail-order service, thereby limiting patient choices.
Earlier this month, the U.S. Federal Trade Commission issued a similar report, highlighting that growing vertical integration among PBMs allows the six largest firms to manage nearly 95% of prescriptions across the nation.
The findings raise significant concerns, with the FTC noting that leading PBMs possess considerable influence over Americans’ access to and affordability of prescription medications. They suggest that vertically integrated PBMs may prioritize their own affiliated businesses, resulting in conflicts of interest that disadvantage independent pharmacies and elevate drug costs. FTC Chair Lina M. Khan remarked that the evidence indicates these intermediaries are significantly inflating prices for cancer medications, generating over $1 billion in additional revenue.