A recent report from the House Committee on Oversight and Accountability highlights that pharmacy-benefit managers (PBMs) are directing patients towards more expensive medications and limiting their pharmacy choices. The report, which was reviewed by the Wall Street Journal, follows a 32-month investigation ahead of an upcoming hearing featuring executives from the largest PBMs in the country.
PBMs serve as intermediaries managing prescription drug plans for health insurers, negotiating costs with pharmaceutical companies and determining the out-of-pocket expenses for patients. The three largest PBMs—Express Scripts, OptumRx (part of UnitedHealth Group), and Caremark (affiliated with CVS Health)—control about 80% of prescriptions in the U.S.
The committee’s findings reveal that PBMs have established preferred drug lists that often favor high-priced brand-name drugs over more affordable generics. For instance, emails from Cigna staff urged against using less expensive alternatives to Humira, an arthritis treatment costing around $90,000 annually, despite the availability of a comparable biosimilar at half that price.
Moreover, Express Scripts reportedly informed patients that fulfilling prescriptions at local pharmacies would be more costly than obtaining a three-month supply through its own mail-order service, thereby restricting patient choice.
Earlier this month, the U.S. Federal Trade Commission (FTC) issued a similar report asserting that the growing consolidation within the industry has allowed the six largest PBMs to manage nearly 95% of all U.S. prescriptions. The FTC’s findings indicate that leading PBMs wield significant influence over the accessibility and affordability of prescription drugs, potentially favoring their own affiliated businesses and disadvantaging independent pharmacies, resulting in higher drug prices.
FTC Chair Lina M. Khan emphasized that the reported practices indicate that these intermediaries are excessively charging patients for cancer medications, accruing an extra revenue of over $1 billion.