Matt Cover’s Sept. 23 op-ed sought to paint pharmacy benefit managers (PBMs) as good actors trying to keep prices low for patients. In doing so, he got one thing right — flashy headlines don’t lower prices — but he leaves out the core driver of high drug costs: PBM opacity that drives up prices at the pharmacy counter.
I currently occupy a seat on the PBM council mentioned in this op-ed but failed to attend this meeting. I am a pharmacist that owns and operates my pharmacy most days of the week providing a high level of care to Louisiana residents. Most days I find it too difficult and expensive to break away from patient care to attend meetings. Local, independent pharmacies like mine operate on small profit margins and often struggle to keep the doors open. The largest challenge I face is not the cost to acquire drugs, staffing, payroll, expenses etc. The largest challenge I face is getting paid fairly by PBMs.
Unfair payment to pharmacies leads to reduced access to care for Louisiana residents. If small pharmacies close or cannot afford to lose money on prescriptions, customers must find alternative ways to obtain these important medications.
Cover begins by misrepresenting what happened at Louisiana’s PBM Oversight Monitoring Advisory Council meeting, claiming that PBMs “were not given a seat at the table.” This is false. Employees from Caremark, Express Scripts and OptumRx were all present at the meeting. Express Scripts even holds a seat on the council, which has repeatedly invited PBMs to present in the same manner as Cost Plus Drugs. So far, they have not.
During the meeting, Express Scripts’ representative, Linus Jordan, responded directly to testimony by Cost Plus co-founder and CEO Dr. Alex Oshmyansky, who detailed how common PBM practices such as hidden rebates, spread pricing, claw backs and vertical integration double the cost of medicine and leave patients paying inflated prices.
He described pricing strategies — particularly with insulin — where PBMs favored the higher-priced option because it yielded larger rebates, even when cheaper alternatives were available. Dr. Oshmyansky also praised Louisiana’s Act 474 for its transparency provisions, which include prohibiting spread pricing and patient steering, as well as mandating NADAC-based reimbursement.
In response, Jordan of Express Scripts acknowledged some of Oshmyansky’s points but defended PBMs as providers of “whole person health” and specialty care management. He also noted that Express Scripts offered $25 insulin before federal requirements. But when legislators pressed Jordan about why rebate returns from Express Scripts lagged far behind much smaller PBMs, Jordan admitted he could not explain the discrepancy. That exchange underscores the very opacity Act 474 seeks to address.
Cover argues that flashy headlines don’t lower prices. On this point, we agree. But neither do the PBMs’ secret contracts, offshore rebate arrangements or opaque claw back practices — all documented by two Federal Trade Commission reports published in 2024 and 2025. Patients cannot afford to subsidize a business built on undisclosed deals between PBMs and drug manufacturers. Cost-sharing based on inflated list prices forces patients to pay more, while rebates and fees are retained elsewhere in the system.
The scale of the problem is staggering. Just three PBMs control 80% of all prescriptions in the U.S. Their affiliated pharmacies bring in 70% of all specialty drug revenue. According to the FTC, in one case alone, two cancer drugs generated $1.6 billion in excess revenue in just three years. PBMs play doctor, controlling which drugs are covered, while patients suffer and line the pockets of major corporations that stand between them and the care that they desperately need.
PBMs have turned “specialty drugs” into a profit scheme. Many of these medicines require no special handling, yet patients are charged thousands of dollars each month for drugs that can cost as little as $30. By labeling common drugs like insulin and adalimumab as “specialty,” PBMs block community pharmacies and steer patients to their own affiliated pharmacies.
As a pharmacist, I see this every day. I currently have a patient with atrial fibrillation that must use a specific PBM-owned specialty pharmacy, even though the medication comes in a bottle of 60 tablets, ready to dispense, under $10 with no special storage or other concerns.
And that’s by the PBMs’ design. Over and over again, the FTC findings show that the dominant PBM model often keeps savings from reaching patients through exclusionary rebates, steering and internal spreads. That’s not leverage working for patients; that’s opacity working against them.
The people of Louisiana will not be misled. We will continue to pursue reforms that enable a system where the medicine their doctor prescribes is covered at the lowest net price — no games, no shadows.
Sunlight and accountability, not secretive corporate middlemen, are what keep drug prices low.
