A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients toward more expensive medications while restricting their pharmacy options. This report follows a 32-month investigation and precedes a hearing involving executives from the largest PBMs in the U.S.
PBMs serve as third-party administrators for prescription drug plans, negotiating pricing with pharmaceutical companies on behalf of health insurers. They also determine the out-of-pocket costs patients face.
The three largest PBMs in the country—Express Scripts, OptumRx (part of UnitedHealth Group), and CVS Health’s Caremark—manage around 80% of prescriptions in the U.S.
According to the committee’s findings, PBMs often create preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives. The report points to communications from Cigna staff, which discouraged the use of cheaper options for Humira, a commonly prescribed arthritis drug that cost $90,000 annually at that time, even though a biosimilar was available for half that price.
Additionally, Express Scripts reportedly informed patients they would pay more if they filled a prescription at a local pharmacy compared to receiving a three-month supply from its affiliated mail-order service. This practice limits patient choice regarding their pharmacy selections.
The Federal Trade Commission (FTC) echoed these concerns in a recent report stating that increasing consolidation in the industry has allowed the six largest PBMs to control nearly 95% of all filled prescriptions in the U.S.
The FTC cautioned that this situation gives PBMs significant influence over patients’ access to affordable medications, leading to potential conflicts of interest and increased drug costs due to their preference for their own affiliated businesses. FTC Chair Lina M. Khan noted that findings indicate these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional profits.