PBMs steer patients away from independent pharmacies to their own vertically integrated mail-order pharmacies, pocketing $1.6 billion in excess revenue on just two cancer drugs

The three largest PBMs -- CVS Caremark (owned by CVS Health), Express Scripts (owned by Cigna), and OptumRx (owned by UnitedHealth Group) -- control nearly 80% of all prescriptions filled in the United States. Each owns its own mail-order and specialty pharmacies. When a patient tries to fill a specialty prescription at an independent or non-affiliated pharmacy, the PBM can impose prior authorization requirements, mandate mail-order fulfillment, set higher copays for non-affiliated pharmacies, or simply exclude non-affiliated pharmacies from the network. The FTC's 2024 interim staff report found that PBM-affiliated pharmacies for these three companies retained nearly $1.6 billion in excess revenue on just two cancer drugs in under three years. For patients, this means losing their relationship with a pharmacist who knows their medication history, health conditions, and other prescriptions. For cancer patients specifically, it means receiving chemotherapy drugs by mail instead of from a specialty pharmacist who can monitor side effects and adjust timing. For independent pharmacy owners, it means losing the highest-margin prescriptions (specialty drugs) to PBM-owned competitors, while being forced to fill the low-margin generics that remain. This accelerates the financial death spiral for independents: specialty prescriptions are the only segment with margins high enough to subsidize below-cost generic reimbursements, and when those are siphoned away, the pharmacy's entire business model collapses. This problem is structural because the same company that decides which pharmacy a patient must use (the PBM) also owns the pharmacy it steers patients toward. Arkansas and Arizona passed laws in 2025 prohibiting PBMs from owning pharmacies in their states -- the first laws of their kind -- but the largest PBMs immediately sued to block Arizona's law, and a judge issued an injunction. At the federal level, PBM reform legislation passed in 2025 for the first time in 20 years, but it focused on transparency requirements rather than structural separation. The conflict of interest is baked into the corporate structure of these conglomerates, and it will persist as long as the same entity acts as both referee and player.