A recent report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) are guiding patients toward costlier medications while restricting their pharmacy options. This report emerged after a 32-month investigation by the committee, coinciding with an upcoming hearing featuring executives from major PBMs.
PBMs serve as intermediaries for prescription drug plans, negotiating prices between health insurers and pharmaceutical companies, as well as establishing out-of-pocket costs for patients. The three largest PBMs—Express Scripts, OptumRx (a part of UnitedHealth Group), and Caremark (owned by CVS Health)—together account for approximately 80% of prescriptions filled in the United States.
The committee’s findings indicated that PBMs have developed preferred drug lists favoring higher-priced brand medications over less expensive alternatives. For instance, the report highlighted emails from Cigna that discouraged the use of cheaper alternatives to Humira, a treatment for arthritis and other autoimmune conditions costing around $90,000 annually, despite the availability of a biosimilar at half that price.
Additionally, the committee noted that Express Scripts informed patients they would pay more for prescriptions at local pharmacies compared to a three-month supply through its affiliated mail-order service, effectively limiting patient choice regarding pharmacy selection.
A similar report from the U.S. Federal Trade Commission (FTC) released earlier this month stated that the six largest PBMs now manage nearly 95% of all prescriptions filled in the U.S. The FTC identified serious concerns regarding the significant influence these leading PBMs have on patients’ access to affordable medications. This concentration raises potential conflicts of interest, suggesting that vertically integrated PBMs might prioritize their own affiliated services over unaffiliated pharmacies, thereby driving up drug costs.
FTC Chair Lina M. Khan expressed that the findings illustrate how these intermediaries are “overcharging patients for cancer drugs,” generating over $1 billion in additional revenue for the PBMs.