PBMs: The Most Powerful Players You’ve Never Met

Pharmacy Benefit Managers, or PBMs, play a much bigger role in healthcare than most people realize. They began in the 1960s as companies that helped insurance plans process prescription claims. Over time, they evolved into powerful middlemen who now manage drug formularies, set copays, decide which pharmacies patients can use, and determine reimbursement rates. Today, three companies: CVS Caremark, Express Scripts, and OptumRx, control nearly 80 percent of the prescription benefits market in the United States.

Many pharmacists and independent pharmacy owners argue that PBMs have strayed from their original mission of lowering costs and are now contributing to higher ones. PBMs profit at multiple points along the drug supply chain by keeping manufacturer rebates, using spread pricing (billing insurers more than they pay pharmacies), and steering patients toward their own mail-order or retail chains. Independent pharmacies often report being reimbursed below cost, making it difficult to stay open. Investigations in states like Ohio and Kentucky have found PBMs overcharging Medicaid programs and underpaying local pharmacies, raising concerns about transparency and oversight. Without strong regulation, critics say PBMs are operating in a system that benefits shareholders more than patients.

PBMs see things differently. They claim to be one of the few forces keeping prescription drug prices from climbing even higher. Industry data suggests PBMs save the healthcare system over $1.2 trillion between 2025 and 2034, averaging about $1,154 in savings per person each year. They also argue that their programs improve medication adherence, reduce waste, and promote generics and more affordable treatment options. For complex or high-cost conditions, PBMs highlight their role in managing specialty drugs and coordinating care to prevent hospitalizations and serious complications.

Both perspectives carry weight. PBMs clearly bring negotiating power and structure to a fragmented drug market, but that power comes with trade-offs that often fall on pharmacies and patients. As policymakers continue debating PBM reform, the challenge will be finding balance, ensuring that PBMs continue to lower costs and streamline care while increasing transparency and protecting community pharmacies that patients rely on most.

📊 Industry Trend:

Fighting Financial Toxicity: How Pharmacists Are Powering Oncology Drug Donation Programs

The rising cost of cancer treatment isn’t just a clinical issue, it’s fast becoming a financial crisis. Too many patients are skipping doses, delaying care, or forced to choose between their medications and basic needs. In response, pharmacists are stepping up with a creative (and practical) solution: organized drug-donation programs that redistribute unused, unopened oncology medications.

Here’s how it plays out. Many health systems or patients end up with specialty oncology drugs, often unopened or unused, because of therapy changes, adverse effects, or dose adjustments. At the same time, other patients struggle to access those same treatments. Rather than letting perfectly good medication go to waste, programs such as SIRUM enable pharmacies and clinics to collect surplus oncology drugs and donate them to patients in need. This isn’t just altruism, it’s smart resource management: less waste, more access, and ultimately, lives potentially saved.

Pharmacists are central in making these programs work. They identify eligible surplus medications (sealed, unexpired, non-controlled), coordinate intake and storage, ensure legal and regulatory compliance, match donated drugs to appropriate patient profiles, and serve as liaisons between health systems and charitable pharmacies. The result: a win-win for patients facing cost barriers, for health systems reducing disposal burdens, and for the environment avoiding unnecessary pharmaceutical waste.

The impact is real. Estimates suggest that billions of dollars worth of oncology medications are wasted annually, numbers in the $2 billion to $3 billion range. Meanwhile, more than 60% of cancer patients and survivors report difficulty affording their care. By redirecting those unused medications, donation programs help shrink the gap between treatment-need and treatment-access. One major donor/redistributor has already facilitated hundreds of millions of dollars’ worth of medicine reaching patients who otherwise might not afford it.

In short: when pharmacists engage in drug-donation programs, they’re not just dispensing, they’re strategically intervening in the financial toxicity of oncology care. And in an era where high-cost therapies dominate, that role is more critical than ever.

🗞  Quick Scripts: Other Industry News

BridgeBio Pharma’s Muscular Dystrophy Therapy Hits Phase III Success

BridgeBio Pharma announced that its investigational therapy for limb-girdle muscular dystrophy met key Phase III endpoints this month, marking a major step forward for rare-disease treatment. The company plans to submit for FDA approval soon, potentially introducing one of the first disease-modifying therapies for this condition. For pharmacists and clinicians, this means the pipeline for rare neuromuscular therapies is expanding quickly, bringing new considerations for specialty pharmacy access, monitoring, and patient counseling. Read more here

Pfizer CEO Calls for U.S./China Biotech Collaboration

Speaking at the National Committee on U.S.–China Relations Gala, Pfizer CEO Albert Bourla urged greater collaboration between U.S. and Chinese biotech firms, noting that China now accounts for nearly 30 percent of global drug development activity. The statement comes as geopolitical and supply-chain pressures challenge pharmaceutical innovation worldwide. For the healthcare industry, this could signal a push toward more globalized research partnerships, faster clinical trials, and potential shifts in manufacturing and regulatory strategy. Read more here

U.S. CDMO Market Projected to Surge to $65 Billion by 2033

A recent market analysis forecasts the U.S. contract development and manufacturing organization (CDMO) sector to grow from about $39 billion in 2025 to over $65 billion by 2033, driven by increased demand for biologics, gene therapies, and complex manufacturing. For hospital and health-system pharmacists, this growth could mean a more resilient manufacturing pipeline but also new challenges in supply coordination and quality oversight. Read more here

Drug Spotlight:

Jascayd (nerandomilast)

Indication: Idiopathic Pulmonary Fibrosis (IPF)

Approval Date: October 2025 | Manufacturer: Boehringer Ingelheim

Jascayd is the first new treatment approved for idiopathic pulmonary fibrosis in more than ten years. The drug targets phosphodiesterase-4B (PDE4B), an enzyme involved in inflammatory and fibrotic signaling pathways. By inhibiting PDE4B, Jascayd helps slow the scarring process in lung tissue that makes IPF so progressive and difficult to treat.

In the Phase 3 FIBRONEER trials, patients taking Jascayd experienced a smaller decline in forced vital capacity (FVC) over one year compared to placebo, and some subgroups saw lower mortality risk. The most common side effects included diarrhea, nausea, and fatigue.

For pharmacists, the approval expands options in a space that hasn’t seen innovation since pirfenidone and nintedanib. Monitoring for GI tolerance and adherence will be key, as will coordinating with pulmonology teams to determine if background antifibrotic therapy remains appropriate. Read more here

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