A new report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications and restricting their pharmacy choices. The report, which emerged after a 32-month investigation, anticipates an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with drug manufacturers and setting patients’ out-of-pocket expenses. The three dominant PBMs in the United States—Express Scripts, OptumRx (a subsidiary of UnitedHealth Group), and Caremark (part of CVS Health)—manage around 80% of all prescriptions in the country.
The committee discovered that PBMs have developed lists of preferred medications that favor higher-priced brand-name drugs over less expensive alternatives. As part of the findings, the report highlighted internal communications from Cigna that discouraged the use of cost-effective alternatives to Humira, an arthritis treatment priced at $90,000 annually, despite the availability of a comparable biosimilar for half that amount.
Furthermore, the committee noted that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to utilizing its affiliated mail-order service. This practice limits patients’ pharmacy options.
In a related report, the U.S. Federal Trade Commission (FTC) stated that increasing consolidation among PBMs has allowed the six largest firms to control nearly 95% of prescriptions filled in the U.S. The FTC described the findings as concerning, indicating that leading PBMs hold substantial influence over Americans’ access to affordable medications. The report emphasized potential conflicts of interest arising from vertically integrated PBMs favoring their affiliated businesses, which may disadvantage independent pharmacies and escalate drug prices.
FTC Chair Lina M. Khan pointed out that these middlemen are significantly inflating costs for cancer medications, contributing over $1 billion to their revenues.