For years, Americans have been told that high prescription drug prices are simply the cost of innovation. But for millions of patients struggling to afford medications, that explanation rings hollow. Roughly a third of American adults report difficulty paying for prescription drugs, and many are forced to skip doses, delay refills, or abandon treatment altogether.
The reality is that there is no single villain behind America's drug pricing crisis. Pharmaceutical manufacturers deserve scrutiny for the high prices many Americans pay for prescription drugs, but they are only part of the story. Between drugmakers and patients stand pharmacy benefit managers, or PBMs, some of the most powerful and least understood players in healthcare, with growing influence over which drugs are covered, which companies succeed, and how billions of dollars flow through the prescription drug market.
Originally created to process prescription claims and negotiate discounts on behalf of health plans, PBMs have evolved into some of the most powerful gatekeepers in American healthcare. Today, three companies, CVS Caremark, Express Scripts, and Optum Rx, reportedly control around 80 percent of the prescription drug market. Through their control of formularies, the lists of drugs covered by insurance plans, these companies have enormous influence over which medicines patients can access and which manufacturers succeed.
In theory, PBMs use their size to negotiate lower prices. In practice, critics argue the incentives often work differently. Rebates paid by drug manufacturers are frequently tied to a drug's list price, meaning higher-priced drugs can generate larger rebates.
According to a 2024 Federal Trade Commission complaint, this dynamic helped create a system in which high-priced insulin products were favored over lower-cost alternatives, illustrating a broader concern that PBM rebate structures can sometimes reward more expensive medicines even when cheaper options are available. The FTC alleged these practices contributed to rising insulin prices and increased costs for vulnerable patients.
The FTC raised additional concerns in 2025, reporting that the three largest PBMs imposed markups of hundreds, and in some cases thousands, of percent on certain specialty generic drugs used to treat conditions such as cancer and HIV. The agency also found that PBM-affiliated pharmacies generated more than $7.3 billion in revenue above estimated drug acquisition costs between 2017 and 2022, prompting questions about whether vertically integrated PBMs may have financial incentives to steer patients toward affiliated pharmacies and higher-cost products.
Earlier this year, an investigation by Hunterbrook Media raised further questions about the industry's largest PBMs. The report focused on three little-known PBM affiliates, Ascent, Emisar, and Zinc, which generate enormous revenue despite having small staffs and little public visibility. According to the investigation, industry experts and former insiders questioned whether these entities serve functions beyond those already performed by PBMs and whether they may provide additional channels for collecting fees and rebates while PBMs continue to advertise rebate pass-through arrangements to clients.
Scrutiny of PBMs has continued to intensify. In 2026, the FTC launched a healthcare task force focused on consolidation and anticompetitive conduct, while separate class action lawsuits accused CVS Caremark and Express Scripts of improperly routing rebate payments through affiliated entities including Zinc and Ascent. The companies have denied the allegations.
Those concerns are particularly relevant in rare diseases such as transthyretin amyloid cardiomyopathy, or ATTR-CM, where patient pools are smaller and treatment costs are often extraordinarily high. Vyndamax, Pfizer's treatment for ATTR-CM, was described as the most expensive cardiovascular drug ever launched in the United States when it entered the market. More recently, the Institute for Clinical and Economic Review concluded that the therapy would require a substantial discount from its annual list price of nearly $268,000 to meet commonly accepted cost-effectiveness thresholds.
Notably, a lower-priced alternative, BridgeBio's Attruby, recently entered the market with patient copay caps designed to improve affordability. Yet critics argue that PBM rebate structures can still favor higher-priced products that generate larger rebates. In the ATTR-CM market, concerns have been raised that Pfizer's rebate arrangements around Vyndamax may make it more difficult for newer competitors to secure formulary access, despite offering lower-cost alternatives. Critics argue that a dominant manufacturer can offer PBMs rebates that newer rivals cannot match, creating strong incentives to favor the incumbent drug. As a result, competitors may struggle to gain market access even when they offer a lower-priced treatment or claim clinical advantages in efficacy. Supporters of reform argue these rebate-driven dynamics can weaken competition and reduce the likelihood that patients benefit from lower-cost treatment options entering the market.
For patients with ATTR-CM, access to treatment can be life-changing, yet access often depends not only on the manufacturer that sets the price, but also on the PBMs that determine formulary placement and insurance coverage.
Patient advocacy organizations have increasingly raised concerns that PBM practices can limit access to needed treatments and increase out-of-pocket costs for patients. As Pamela Gavin, Chief Executive Officer of the National Organization for Rare Disorders, recently stated: "It remains unacceptable that access to life-saving care still depends on where a family lives... Policymakers must strengthen protections so patients can access treatment without facing devastating financial hardship." Similar concerns have been raised about the role PBMs play in determining access to medicines. Terry Wilcox, Co-Founder and Chief Executive Officer of Patients Rising, has described the current system as "a shell game of hidden fees and broken promises, leaving patients to pay the price."
The result is a system that many argue rewards scale and negotiating leverage, sometimes at the expense of transparency and competition. Drug manufacturers retain significant pricing power, while PBMs exert growing influence over which treatments receive preferred coverage and broad patient access.
These concerns have helped fuel growing calls for reform from policymakers across the political spectrum. While proposals differ, many share a common goal: increasing transparency and competition throughout the pharmaceutical supply chain while addressing both the pricing power of drug manufacturers and the influence of PBMs. Without meaningful reforms, concerns about affordability, access, and market concentration are likely to persist.
