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Cole’s family alleges that a pharmacy benefit manager formulary change caused the inhaler he relied on to become unaffordable. No one communicated it.

I’ve spent over 20 years inside the prescription drug supply chain helping employers understand where their healthcare dollars go. Prescription drugs can make up nearly 40% of companies’ healthcare spending. 

Somehow, the middlemen originally created to help lower drug costs are instead profiting from high drug prices.

Nearly 80% of U.S. prescription drug claims are routed through three PBMs: OptumRx (owned by UnitedHealth Group), Express Scripts (owned by Cigna), and CVS Caremark (owned by CVS Health, which also owns Aetna). Ninety-five percent of prescriptions in the United States touch a PBM. Most Americans don’t know what a PBM is until a medicine they need suddenly isn’t covered, costs hundreds more overnight, or disappears behind a prior authorization wall.

That’s not transparency, it’s life-threatening chaos.

Employers and families are paying the price. In 2025, the average family premium for employer coverage climbed to nearly $27,000, a painful increase when healthcare costs remain a top economic anxiety.

Many employers can’t fully see where the money is going. PBM contracts are notoriously opaque, with rebates, spread pricing, fees few can decipher, making costs hard to track. 

The cracks are starting to show. 

A Federal Trade Commission investigation found the country’s biggest PBMs marked up some specialty generic drugs by hundreds — sometimes thousands — of percent, generating billions in revenue. An Ohio analysis found that PBMs pocketed $223.7 million from Medicaid managed care programs in one year, excluding rebates and additional fees. 

PBMs argue that the drug companies are the real problem, and drug companies deserve the scrutiny. But PBMs also benefit from higher drug prices because larger rebates can mean larger profits. 

There’s good news in PBM reform momentum. 

Congress recently passed PBM reforms through the Consolidated Appropriations Act of 2026, increasing transparency and changing rebate practices in Medicare Part D. The reform is projected to save taxpayers $2.12 billion over 10 years.

In one of the most surprising bipartisan alliances in healthcare, Sens. Josh Hawley (R-MO) and Elizabeth Warren (D-MA) teamed up to reintroduce the Patients Before Monopolies Act. Their bill challenges vertically integrated healthcare giants by targeting overlapping ownership among insurers, PBMs, pharmacies, and drug wholesalers. 

President Donald Trump’s executive order on drug pricing means PBM reform is no longer some niche healthcare conversation happening among wonks. 

States have enacted dozens of PBM reform bills over the last two years. In Wisconsin, Schmidtknecht’s family is advocating “Cole’s Act,” a bill to crack down on PBMs.

I lean into my “PBM Princess” nickname — and business name. Healthcare needs advocates who can explain this system in plain English. And yes, I also like pink. 

Employers and patients deserve to understand what they’re paying for and whether the system is serving them. 

We can’t afford to move slowly while families stand at pharmacy counters making impossible choices.

OPINION: TRUMP’S TWO-FRONT FIGHT TO LOWER DRUG PRICES IS ALREADY WORKING

Schmidtknecht should still be here.

If his story doesn’t force us to ask harder questions about this broken system, what are we waiting for? 

Houston healthcare advocate Rachel Strauss is a longtime pharmacy benefit consultant and patient advocate focused on exposing hidden pricing practices within the PBM industry. She educates employers, consumers, and policymakers about how rebates, spread pricing, and opaque contracting can inflate medication costs and limit patient choice. Through social media, speaking engagements, and a new documentary project, Strauss translates complex healthcare pricing issues into practical, consumer-focused information at a time when PBM reform is gaining bipartisan momentum nationwide.