A recent report from the House Committee on Oversight and Accountability alleges that pharmacy-benefit managers (PBMs) are directing patients toward more costly 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 nation.
PBMs serve as intermediaries for prescription drug plans offered by health insurers, negotiating prices with pharmaceutical companies and determining patient out-of-pocket costs. The three largest PBMs—Express Scripts, OptumRx (a UnitedHealth Group subsidiary), and CVS Health’s Caremark—are responsible for managing around 80% of prescriptions in the United States.
According to the committee’s findings, PBMs often prioritize higher-priced brand-name drugs over cheaper alternatives on their preferred drug lists. For instance, the report references communications from Cigna employees that discouraged using less expensive substitutes for Humira, a medication for arthritis and other autoimmune disorders, which was priced at $90,000 annually, while at least one biosimilar was available for half that amount.
Additionally, the committee revealed that Express Scripts informed patients they would incur higher costs if they filled prescriptions at their local pharmacies rather than obtaining a three-month supply through its affiliated mail-order service, thus limiting patients’ pharmacy choices.
This aligns with an earlier report from the U.S. Federal Trade Commission (FTC), which noted that heightened vertical integration and concentration allow the six largest PBMs to control nearly 95% of prescriptions filled in the country.
The committee expressed concern over the significant influence that leading PBMs wield over Americans’ access to affordable prescription drugs, potentially favoring their own affiliated businesses. FTC Chair Lina M. Khan highlighted a troubling trend where these intermediaries might be “overcharging patients for cancer drugs,” resulting in over $1 billion in additional revenue for them.