Most people don't think twice about the small line on their insurance card that reads "prescription benefits." Yet behind that single line lies an entire industry shaping how Americans access and afford medications. That industry is powered by Pharmacy Benefit Managers, or PBMs, companies that manage prescription drug benefits on behalf of insurers, employers, and patients.
"PBMs are the intermediaries in the healthcare system," explains Greg Baker, Chief Executive Officer at AffirmedRx. "We sit between pharmaceutical manufacturers, insurers, and pharmacies, negotiating prices, creating formularies, and administering drug benefits. In the simplest sense, we work diligently to control costs, but in reality, the industry has become incredibly complex."
For decades, many Americans had little reason to know what PBMs were. But as prescription drug prices skyrocketed, the role of PBMs came under greater scrutiny. Some argue that the system became opaque by design, with rebates and behind-the-scenes negotiations benefiting middlemen more than patients. Today, the largest traditional PBMs control nearly 80% of the market.
"The traditional PBMs dominate through vertical integration and tactics that don't always serve patients or employers," says Baker. "That's why the timing of this conversation is so important. Transparency in PBMs is no longer a buzzword; it's a necessity."
One of the most misunderstood but critical aspects of PBM work is the formulary, essentially a list of approved drugs covered by an insurance plan. Formularies influence which drugs patients can access affordably and which remain out of reach.
"Our formulary is public and available on our website," Baker emphasizes. "That level of transparency is rare. For most PBMs, you will never know why certain drugs are included or excluded. We believe people deserve to see the decision-making process."
Beyond formularies, AffirmedRx differentiates itself through direct patient support. The company employs a group of Patient Care Advocates (PCAs) who proactively assist members facing medication challenges. Baker shared a recent case where a patient paid out-of-pocket for a prescription that should have been covered. "Within 24 hours, one of our advocates called the patient, explained the issue, and guided the individual through getting reimbursed," he says. "The patient didn't even have to contact us; we reached out first. That kind of proactive and personalized care is quite rare in this industry."
AffirmedRx's commitment to transparency is rooted in its legal structure as a Public Benefit Corporation (PBC). Unlike traditional for-profit corporations, PBCs are required to balance profit-making with a measurable public good. "Becoming a PBC was a deliberate decision," says Baker. "I entered this industry to make meaningful change because of its flaws. I recognized that profit-driven motives had contributed to many issues. By building AffirmedRx as a public benefit company, we have hardwired into our DNA the responsibility to serve people, not just shareholders."
This ethos is reinforced through AffirmedRx's membership in TransparencyRx, a coalition of like-minded organizations working to reform the PBM model. Alongside partners, the group is pushing for an industry where pricing and rebate flows are visible to employers and patients alike.
Still, challenges remain. Employers must weigh scale, cost, and service quality when selecting a PBM partner. For many, defaulting to the dominant players feels safer. But Baker urges employers to look beyond the comfort of brand familiarity. "If an employer can't understand where the money is going, that's a red flag. True transparency means knowing how rebates are handled, what drugs are a part of your formulary, and having a shared commitment to openness with patients about decisions being made. When these parts all come together, the PBM industry moves in a positive direction."
AffirmedRx embraces a mix of family values, underdog grit, and Midwestern pragmatism. It's a culture that resists a profit-first mentality. "We are the underdog," Baker says, "but we believe the underdog will win by doing the right thing. That's why I chose to enter this realm and embark on this mission. In an industry as complex and misunderstood as PBMs, honesty and transparency matter more than anything."
As healthcare costs continue to rise and legislative scrutiny intensifies, the role of PBMs will only become more prominent. Employers, policymakers, and patients alike need to understand the mechanics of this industry and how new models like AffirmedRx are proving that a different path is possible.
"The PBM conversation is finally in the spotlight," Baker says. "For years, only a few knew what we did. Now, people are asking the right questions. And when they do, they deserve straightforward answers."
