A recent report from the House Committee on Oversight and Accountability has raised concerns about pharmacy-benefit managers (PBMs), alleging they are directing patients towards more expensive medications while restricting their choice of pharmacies.
The findings, highlighted by the Wall Street Journal, result from a 32-month investigation and precede a hearing featuring executives from some of the largest PBM companies in the nation. PBMs, which act as intermediaries between insurers and pharmaceutical companies, determine the costs of drugs for health plans and set out-of-pocket expenses for patients.
The report emphasizes that the three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—control around 80% of prescriptions in the United States. According to the committee, these PBMs have developed preferred drug lists that favor higher-priced brand-name medications over more affordable alternatives.
For instance, correspondence within Cigna was cited in the report discouraging the use of lower-cost substitutes for Humira, a medication costing $90,000 annually, despite the availability of a biosimilar at half that price. Moreover, Express Scripts allegedly informed patients that filling prescriptions at local pharmacies would be more expensive than obtaining a three-month supply through their own mail-order service, thereby restricting patients’ pharmacy options.
Earlier in the month, the U.S. Federal Trade Commission (FTC) released a report echoing these findings. The FTC’s interim report noted that the concentration of power among the six largest PBMs allows them to oversee nearly 95% of all prescriptions in the U.S.
These developments have raised alarm within the committee, which stated that the leading PBMs wield considerable influence over Americans’ access to and affordability of prescription drugs. The FTC commented that the current structure allows vertically integrated PBMs to favor their own affiliated businesses, resulting in conflicts of interest that could disadvantage independent pharmacies and inflate drug prices.
FTC Chair Lina M. Khan highlighted the implications for patients, stating that these middlemen are contributing to exorbitant costs for cancer medications, reportedly generating over $1 billion in additional revenue from this practice.