A new report from the House Committee on Oversight and Accountability reveals that pharmacy-benefit managers (PBMs) may be directing patients toward more expensive medications and restricting their pharmacy choices. The findings were highlighted in a report reviewed by the Wall Street Journal, which follows a 32-month investigation ahead of a scheduled hearing featuring executives from the country’s largest PBMs.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating prices with pharmaceutical companies and determining out-of-pocket costs for patients. The three largest PBMs—Express Scripts, UnitedHealth Group’s OptumRx, and CVS Health’s Caremark—manage about 80% of prescription medications in the U.S.
According to the committee’s report, PBMs have established lists of preferred drugs that favor higher-priced brand-name medications over more affordable options. For instance, the report highlighted emails from Cigna staff that advised against using less expensive alternatives to Humira, an arthritis treatment that was priced at $90,000 annually, despite the availability of a biosimilar for half that cost.
The committee also reported that Express Scripts informed patients they would incur higher costs by using local pharmacies rather than opting for a three-month supply from its affiliated mail-order service, thereby limiting patient choices.
Moreover, a recent report from the U.S. Federal Trade Commission (FTC) echoed similar concerns, noting that increased vertical integration among PBMs has allowed the largest six to manage nearly 95% of all U.S. prescriptions. The FTC warned that this concentration gives leading PBMs substantial control over American access to affordable medications and can create conflicts of interest that hurt unaffiliated pharmacies while inflating drug prices.
FTC Chair Lina M. Khan stated that the report’s findings indicate that these intermediaries are overcharging patients for essential cancer medications, generating excess revenue exceeding $1 billion.