A recent report by the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are directing patients towards more costly medications while restricting their options for obtaining them. The findings come in advance of a hearing featuring executives from the country’s largest PBMs and followed a 32-month investigation.
PBMs act as intermediaries for prescription drug plans offered by health insurers. They negotiate prices with pharmaceutical companies and determine out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (a CVS Health subsidiary)—together manage around 80% of U.S. prescriptions.
The committee’s investigation found that PBMs often create preferred drug lists that favor higher-priced brand-name medications over less expensive alternatives. An example highlighted in the report included emails from Cigna employees urging against the use of cheaper variations of Humira, an arthritis medication priced at $90,000 annually, despite the availability of biosimilars costing half that amount.
The report also indicated that Express Scripts informed patients they would incur higher costs if they filled prescriptions at local pharmacies as opposed to using its mail-order service, effectively limiting their pharmacy options.
A similar report released this month by the U.S. Federal Trade Commission (FTC) noted that increasing consolidation has allowed the six largest PBMs to manage nearly 95% of all prescriptions in the U.S. The FTC expressed concern over the growing influence of PBMs on patients’ access to affordable medications, highlighting potential conflicts of interest that may arise when PBMs favor their own affiliated businesses, potentially disadvantaging independent pharmacies and raising drug prices.
FTC Chair Lina M. Khan emphasized that the data indicates middlemen are significantly inflating costs, particularly for cancer drugs, adding over $1 billion in revenue to their profits.