What You Need to Know About PBMs and Drug Prices

You go to the pharmacy expecting your medication to cost about the same as last month, maybe a small change. But this time, it’s triple the price. You haven’t changed anything. You’re on the same dose, the same refill schedule. So why is it suddenly unaffordable?

Behind that sticker shock is a system that most people never see, but that affects nearly every prescription you fill: pharmacy benefit managers, or PBMs.

They’re the middlemen in the prescription drug world. And they have more control over your out-of-pocket costs than your doctor, your pharmacist, or even your insurance provider.

So who are PBMs, really?

PBMs started as administrators to help insurance companies manage prescription drug claims. But over the years, they’ve grown into power brokers that negotiate with drug manufacturers, decide which medications are covered, and determine how much pharmacies get reimbursed. They set the rules, and often, the prices, without ever speaking to the patient.

Three PBMs now control nearly 80 percent of the market. That’s not a typo. And each is owned by or affiliated with a major health insurance company. That means the people deciding what drugs are covered, and at what cost, are often also the ones profiting from that decision.

How this affects you at the counter.

Let’s say you’ve been filling the same generic medication for years. Then one day, it’s no longer covered. Or it’s covered, but your copay jumped from $10 to $75. That’s a PBM decision. They changed the formulary, the list of drugs they’ve deemed preferred, without warning, and without explanation.

Your pharmacist can’t override it. Your doctor might not even be told. And you’re stuck deciding between paying more or going without.

We’ve seen it happen to seniors on fixed incomes. To parents trying to afford asthma inhalers for their kids. To people managing chronic conditions who can’t afford surprises.

PBMs also control what pharmacies get paid.

When you fill a prescription, the PBM decides how much your local pharmacy is reimbursed. Sometimes, that amount is less than what the drug costs the pharmacy to purchase. Pharmacies lose money just for helping you access your medicine. That model isn’t sustainable. And it’s one of the reasons so many independent pharmacies are closing their doors.

So what can you do?

Start by asking questions. If your medication price suddenly changes, ask your pharmacist why. They may not be able to change it, but they can explain what’s going on behind the scenes. Sometimes, they can suggest a covered alternative, or help you access discount programs outside of your insurance.

Look into transparent pricing options. Some services, like the Mark Cuban Cost Plus Drug Company, skip PBMs altogether and offer clear, consistent prices. It’s worth comparing.

Support legislative efforts that hold PBMs accountable. Several states are introducing bills that demand more transparency, fairer reimbursement, and patient-centered policies. These efforts only gain traction when patients and pharmacists speak up.

If you’re choosing a new insurance plan, ask how prescriptions are handled. What PBM do they use? What kind of control do you have over your drug coverage?

And finally, stay informed. The more people understand how PBMs work, the harder it becomes for those practices to stay hidden.

Because healthcare shouldn’t feel like a guessing game. Especially when your health is on the line.

Ask the hard questions. Demand clarity. Advocate for better. Because you’re not just a patient. You’re the one paying the price.

And you deserve a system that puts you first.