PBMs and Insurers

A small number of giant health care conglomerates dominate the health care system – that means your pharmacy benefit managers (PBMs) and insurers are often the same company.

PBM Middlemen Drive Up Prices

Barries to Access are Worsening

When massive health care conglomerates own the PBM and insurer, they can control which medicines are covered, what patients pay, and where they can fill their prescriptions. As a result patients can face higher costs, fewer choices, and delays in care.

In fact:

70% of patients seeking branded medicines through commercial insurance were initially denied coverage
50% of every dollar spent on medicines goes to middlemen and others who don’t make medicines
1,000%+ markups on medicines are dispensed at PBM-owned pharmacies

This isn’t just about cost – it’s also about quality of life for patients. When PBMs limit access to vital medicines, patients may experience delays, disruptions, and negative health impacts.

“Medications I had been taking for over 20 years, they [my insurer] said no, you can’t take that now.”
— Fred, patient advocate

For patients and families facing serious illness in need of medications, those obstacles can make an already difficult journey even harder.

“I spend a lot of hours on the phone talking to these insurance companies to try and have them give me another inhaler that can possibly save my life. It makes me feel that the insurance companies aren’t thinking about us and that they’re just thinking about the profit that they’re making on the medicines.”
— Renee, patient advocate

While some denials are eventually overturned, the process often creates delays, administrative burdens, and disruptions to treatment. For too many patients, these barriers result in delays or abandoned care altogether

What Congress Can Do

Clear, targeted changes can bring greater accountability to PBMs and relief for patients.

Increase transparency around insurance denials. Streamline prior authorization requirements, hold insurers accountable for providing timely, medically necessary care.
Implement PBM transparency: Make sure PBMs and health plans are accountable by increasing oversight and transparency into the processes they use to manage patient benefits.
Protect patients’ choice of pharmacy: Ensure patients can fill prescriptions at a pharmacy that works for them – not one that will pad PBM profits.
Stop hidden markups: Make sure patients and health programs aren’t overcharged by requiring PBMs to pass along real savings.