A new report from the House Committee on Oversight and Accountability has revealed that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and restricting their pharmacy options. The report, which followed a 32-month investigation, is set to play a central role in an upcoming hearing featuring executives from the country’s largest PBMs.
PBMs act as intermediaries in prescription drug plans for health insurers, negotiating prices with pharmaceutical companies on behalf of health plans, and determining the out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (affiliated with CVS Health)—manage roughly 80% of prescriptions filled in the U.S.
According to the committee’s findings, PBMs maintain lists of preferred medications, favoring higher-priced brand-name drugs over more affordable options. The report highlighted communications from Cigna that discouraged the use of less expensive alternatives to Humira, a costly arthritis treatment, even though a biosimilar was available at significantly lower prices.
Additionally, the report indicated that Express Scripts informed patients that they would incur higher costs by filling prescriptions at local pharmacies compared to obtaining a three-month supply from its associated mail-order service, which the committee noted limited patients’ pharmacy choices.
Earlier this month, the U.S. Federal Trade Commission also released a related report, stating that increased vertical integration and concentration in the industry allowed the six largest PBMs to control nearly 95 percent of all prescriptions filled in the U.S. The FTC’s interim report expressed concerns about the considerable power PBMs wield over access to affordable prescription medications, highlighting that vertically integrated PBMs might prioritize their affiliated entities, leading to conflicts of interest and rising drug costs for consumers.
FTC Chair Lina M. Khan commented that the findings demonstrate how these intermediaries are inflating costs for cancer drugs, generating over $1 billion in additional revenue at the expense of patients.