A new report from the House Committee on Oversight and Accountability accuses pharmacy-benefit managers (PBMs) of guiding patients towards more expensive medications and restricting their pharmacy options. The findings suggest that Medicare patients could collectively save $1.5 billion on ten specific prescription drugs.
This report, which was reviewed by the Wall Street Journal, comes after a 32-month investigation by the committee and precedes a hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries for prescription drug plans managed by health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx from UnitedHealth Group, and Caremark from CVS Health—control about 80% of prescriptions dispensed in the United States.
The report highlights that PBMs maintain lists of preferred drugs that often promote higher-priced brand-name medications over less costly alternatives. An example cited involves Cigna actively discouraging the use of biosimilars for Humira, an arthritis treatment costing $90,000 annually, when a comparable biosimilar was available for half the price.
Additionally, Express Scripts reportedly informed patients that they may face higher costs by filling prescriptions at their neighborhood pharmacy rather than through its affiliated mail-order service, thereby limiting patients’ pharmacy choices.
The Federal Trade Commission (FTC) released a similar report earlier this month, indicating that the six largest PBMs account for nearly 95% of all prescriptions filled in the U.S. According to the FTC, this concentration grants these PBMs extensive control over patients’ access to affordable medications. It also suggests that these vertically integrated PBMs might prefer their affiliated businesses, raising concerns about conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan emphasized that findings reveal middlemen may be overcharging patients for cancer therapies, generating excess revenue exceeding $1 billion.