It may sound counterintuitive, but firms that were created to negotiate better deals for consumers on medicines instead have sometimes driven up the costs of prescriptions — while also putting the survival of community pharmacies at risk.

These firms are called pharmacy benefit managers, or PBMs.

Large employers and health insurance companies pay PBMs to act as middlemen. PBMs are supposed to leverage their purchasing power with pharmaceutical companies to get discounts and rebates, with the goal of controlling prescription drug costs for patients.

To do this, PBMs use strategies including:

• Creating and managing formularies, which are lists of prescription medications that a health insurance plan covers. In cases where there are similar medicines on the market to treat a disease or condition, PBMs and insurers can use the threat of excluding a company’s drug from a formulary to drive discounts. For example, the multinational pharmaceutical company Merck offered bundled discounts on certain asthma and diabetes medicines to ensure that certain products remained on formularies, the company told the Senate Finance Committee in 2019.
• Encouraging use of mail order for routine prescriptions. These are the same strategies that many other large purchasers of medicines, such as the Department of Veterans Affairs, use. The VA uses its mail-order pharmacy to provide about 80% of prescriptions used by its patients outside of hospitals.

What’s drawing widespread criticism and concern about PBMs are the strategies they employ to maximize the profit they can make as middlemen, as well as their dominance in the marketplace. 

Consumers can benefit from lower prices of medicines. But PBMs themselves can benefit more than consumers do in cases where drugmakers start their negotiations with a high initial offer, or list price. PBMs then, eventually, whittle down the actual payment, often by getting pharmaceutical companies to give back some of the money through payments known as rebates. It’s unclear how much of the rebated funds flow back to health plans this way and how much is kept by the PBMs.

PBMs contend the complex negotiations between list price and actual price help both insurers and consumers. These savings gained through negotiations lower the cost of monthly premiums.

But the rebate approach leaves many patients facing sticker shock from out-of-pocket costs at the pharmacy due to the high list prices, with some people then not being able to afford their medicines even though they have health insurance. List prices are not just numbers used in negotiations. 

Many patients must pay part or all of these list prices at the pharmacy, even if the PBMs later whittle the actual spending on medicines through negotiations. That means some of the people most in need of medicine get less help from having insurance, according to the Federal Trade Commission, which argues that PBMs are rigging the pharmaceutical supply chain system in their favor.

“This turns the normal insurance model on its head with the sick subsidizing the healthy rather than the other way around,” the FTC said in an administrative complaint filed in September.

The FTC sues the PBMs

Following an investigation of PBMs that started in 2022, the FTC sued three giant PBMs — CVS Caremark, Cigna Group’s Express Scripts and UnitedHealth’s Optum Rx. Those three companies administer about 80% of all drug prescriptions in the U.S., according to the lawsuit.

Take note: While the FTC refers to this as a lawsuit, it’s important to note that an administrative complaint is a special kind of one. In these cases, the FTC files a complaint to kick off its own administrative process instead of taking the case to a federal court. D. Michael Chappell, the FTC’s chief administrative law judge, has been handling the cases against the PBMs. His decisions and motions filed by the PBMs and by the FTC are posted online on the agency’s website.

The FTC argues that PBMs have created a “intricate and opaque pharmaceutical distribution chain,” allowing them inordinate control of insulin sales and pricing. By threatening to exclude some companies’ products from formularies, they were able to demand larger rebates, leading to the higher list prices.

“Pharmacists from West Virginia to Texas have written to the FTC, expressing concern that PBMs’ business practices are creating risk for their patients while squeezing independent pharmacies that have served their communities for decades,” said FTC Chair Lina Khan in a July statement.

Keep track: Journalists can keep up with legal motions related to the case on the FTC’s web page tracking this matter. This includes documents related to the PBMs’ response to the FTC’s administrative complaint.

The PBMs fight back

The PBMs are fighting back. In November, Express Scripts, Caremark and OptumRx sued the FTC, filing a complaint in a federal district court. The complaint challenges the legal basis for the FTC’s actions and argues that those actions are unconstitutional.

Specifically, the PBM’s complaint takes issue with the FTC’s legal process – using the aforementioned in-house administrative process rather than filing a case in a federal court.

“This sweeping attempt to reshape an entire industry via law enforcement would never pass muster in a U.S. District Court,” the PBM’s complaint reads. “It is therefore unsurprising that the Commission brought this action in its own captive tribunal, where the Commission decides the allegations and the claims, sets the rules, does the fact-finding, chooses what the law is, and determines the outcome.”

The complaint also says the FTC is seeking to “upend present-day drug rebate contracts, forcing PBMs to revamp their entire contracting framework and countless contracts.”

An increase in pharmacy deserts

The number of retail pharmacies owned by giant CVS Health, which owns a PBM, grew by 28% to more than 9,700 locations from 2013 to 2022, said the FTC in a July publication. During this time, the number of other retail pharmacies, including independent pharmacies,  declined by 7% to 51,400 locations, with a 10% drop in rural areas.

The pressure exerted by increasingly powerful PBMs has been linked to the increase in pharmacy “deserts,” or places where residents may not have a retail pharmacy within 10 miles of their homes.

 In the July statement, the FTC outlined challenges to smaller pharmacies. Many smaller independent drug stores use their own middlemen, called pharmacy services administrative organizations, in negotiations with PBMs. Still, the smaller businesses often must operate in the dark, uncertain about how much they will eventually be paid , according to the FTC.

“Pharmacies therefore are often missing a critical variable for basic operational business planning and for making informed choices about which PBMs, which networks, and which drug claims would pay the best—or sustainable—rates,” the FTC statement says. “In other words, pharmacies are commonly reimbursed based on an algorithm with numerous opaque, shifting price inputs.”

Consumer advocates such as Public Interest Research Group (PIRG) and health care lobbying groups such as the American Medical Association and American Hospital Association also have called for greater oversight and stricter controls of PBMs.

Bipartisan support for more transparency

This is a rare health policy issue that has solid bipartisan support.

For example, in an amicus brief filed earlier this year, the attorneys general of 31 states joined to ask the Supreme Court to address conflicting federal court rulings on PBM cases. At issue is a ruling in which the Court of Appeals for the Tenth Circuit held that federal laws preempt Oklahoma laws and thus block state regulation of PBMs. In this case, Oklahoma sought to put in place requirements intended to compel PBMs to work with more pharmacies.  

This lower court ruling appears to conflict with a 2020 Supreme Court ruling on PBMs, noted the bipartisan group, which included attorneys general from states with Democratic governors, like California, and Republican ones, like Florida.

The attorneys general are united in seeking a clear path to allow state regulators to address what they call the PBMs’ “self-serving protections that have reduced reimbursement rates to pharmacies, maximized rebates to PBMs, and imposed various confidentiality requirements to hide PBMs’ business practices.”

“PBMs have thrived behind the scenes, exploiting the lack of transparency that they designed into the system,” the bipartisan group of attorneys general write in their amicus brief.

Pending PBM legislation in Congress also has bipartisan support.

As of early December, the Protecting Patients Against PBM Abuses Act (H.R.2880) has the backing of 27 Republicans and 18 Democrats. This bill would switch PBM reimbursement to flat dollar service fees for sales made through the Medicare Part D pharmacy program, which covers medicines used by people aged 65 and older.

In the Senate, at least 10 Republicans and five Democrats are backing the Pharmacy Benefit Manager Transparency Act of 2023 (S.127). The bill seeks to prevent PBMs from charging health plans and employers more for prescription drugs than what they reimburse to the pharmacy.

Domination by three giants

The FTC and other PBM critics contend remarkable consolidation in the industry has given outsized clout to just three firms, each affiliated with a major health insurer.

Three PBMs handled almost four of every five U.S. prescription drug claims in 2023, according to the FTC. The FTC said the bulk of the market breaks down like this: 

• CVS Caremark, with 34% of the PBM market. It is owned and operated by CVS Health, which also owns the health insurer Aetna along with a major chain of retail pharmacies.
• Express Scripts, with 23% of the PBM market. It is part of the Cigna Group, which sells health insurance plans.
• OptumRx, with 22% of the PBM market. It is part of UnitedHealth Group, which also sells health insurance plans.

PBMs emerge, consolidate

The earliest version of pharmacy benefit managers started in the 1960s in the United States, with firms such as PAID Prescriptions acting as intermediaries between the pharmacists and insurers.

In the early 1990s, several drugmakers acquired PBMs, which they later sold to larger PBMs or to health care conglomerates that included PBMs.

In 2017, the Department of Justice successfully blocked two major mergers involving health insurers: Aetna-Humana and Anthem-Cigna, explain Joseph Mattingly II of the University of Utah, David A. Hyman of Georgetown University and Ge Bai of Johns Hopkins University. They detail this rise of the industry in a 2023 article in JAMA Health Forum, titled “Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy.”

Federal regulations thus rebuffed bids for major horizontal consolidation, the phrase used to describe acquisitions that combine two companies in the same field.

But a year later, regulators allowed large vertical acquisitions, defined as transactions where companies acquire businesses that expand their product and service offerings in new ways. In 2018, pharmacy giant CVS Health acquired insurer Aetna, and insurer Cigna merged with PBM giant Express Scripts.

Broader concerns about PBM business practices, prompted the FTC to open a sweeping inquiry into the PBM industry in 2022.

The FTC intended to produce a full report on the industry, setting the stage for further action. Instead, the FTC in July 2024 released an interim report, noting that several PBMs had not completed the required submissions and thus hindered the commission in its work. Still, there was enough evidence that the FTC voted in September to file an administrative complaint against PBMs focused on insulin.

Employers on the hook

Another legal case of interest is the recent lawsuit filed by a former employee of Johnson & Johnson, Ann Lewandowski, in New Jersey in February.

She contends that a 1974 federal law, the Employee Retirement Income Security Act (ERISA), should compel companies to ensure reasonable prescription drug prices under their health benefit plans. Her complaint cites as evidence of harm the case of a 90-pill prescription for the generic drug teriflunomide, used to treat multiple sclerosis.

The drug can be purchased without insurance at retail and online pharmacies for prices ranging from $28.40 to $77.41. Using Johnson & Johnson’s insurance coverage, reflecting PBM policies, the same prescription would cost “$10,239.69 — not a typo,” the lawsuit says.

“No prudent fiduciary would agree to make its plan and beneficiaries pay a price that is two-hundred-and-fifty times higher than the price available to any individual who just walks into a pharmacy and pays out-of-pocket,” the complaint says.

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Research Roundup

PBMs are a big topic of interest among health policy researchers. The following academic papers can help journalists gain a deeper understanding of the issues at play in the debate about PBMs.

The Implications Of Rutledge v. PCMA For State Health Care Cost Regulation
Erin C. Fuse Brown and Elizabeth Y. McCuskey. Health Affairs blog, December 2020.

Rutledge v. PCMA was a 2020 case in which a trade organization for PBMs sued the attorney general of Arkansas – and eventually lost. In this Health Affairs article blog, the authors, a health policy professor and a law school professor, explain why this case was such a significant win for states seeking to regulate PBMs.

Enacted by Congress in 1974, the Employee Retirement Income Security Act can preempt state laws that relate to employee benefits, including health benefits. This is an extraordinarily broad mandate that “has bedeviled courts and preempted scores of state health care regulations,” the authors write. ERISA is intended to set minimum standards for most voluntarily established retirement and health plans in private industry. But courts “have made a mess of ERISA jurisprudence,” owing in part to the statute’s “inscrutable language” preempting laws that relate to benefits, the authors write.

In 2015, Arkansas passed a law that effectively requires PBMs to reimburse pharmacies at a price equal to or higher than the pharmacy’s cost for purchasing drugs to sell to customers. It also permits Arkansas pharmacies to refuse to sell a drug if the reimbursement rate is lower than its acquisition cost. The trade group for PBMs, the Pharmaceutical Care Management Association, sued, contending that ERISA preempted this Arkansas law.

The case reached the Supreme Court, which ruled 8-0 in favor of Arkansas. In this case, the Supreme Court concluded ERISA does not preempt some state rate regulations. It found cost-control regulation to be beyond ERISA’s scope.

The authors write: “Most immediately, Rutledge puts PBM regulations passed by more than 45 states on much firmer footing. These laws do different things, but they are all aimed at reining in prescription drug costs.”

Pharmacy Benefit Manager Reform: Lessons from Ohio
Trevor J Royce, Sheetal Kircher and Rena M Conti. JAMA, July 2019.

This paper recaps how Ohio became a leader in efforts to regulate PBMs.

Ohio in 2018 directed the insurers that manage its Medicaid program to revise their approach to paying PBMs, effective January 2019. This followed the release of a wide-sweeping audit that appears to have been the first comprehensive review of PBM practices by a government agency in any state or nationwide, the authors write.

These plans were directed to instead adopt a transparent “pass-through” pricing model whereby the Medicaid health plans would pay PBMs the exact amount paid to the pharmacy for the prescription drug, a dispensing fee and, in lieu of spread-based revenue, an administrative fee, the authors write.

This shift addressed concerns about “spread pricing,” where Ohio Medicaid paid high prices for drugs for which local pharmacies received low reimbursement, with a PBM pocketing the difference. For example, the price paid in 2017 to pharmacies for a 30-day supply of the generic leukemia medication imatinib mesylate was $3,859 with the cost to Ohio Medicaid of $7,201, a difference of $3,342.

Ohio state officials and lawmakers also looked at ways to stop PBMs from imposing gag clauses on pharmacists before bipartisan federal legislation passed on this issue.

The authors write: “States have long been fertile testing grounds for health policy innovation and, as has been seen with states’ efforts toward expanding insurance coverage, may act as leaders in improving patient access and affordability to prescription drugs. Ohio has pioneered regulatory efforts to increase PBM accountability, eliminate spread pricing in favor of more transparent pass-through pricing, and reduce the use of pharmacy gag clauses.”

Estimation of the Share of Net Expenditures on Insulin Captured by US Manufacturers, Wholesalers, Pharmacy Benefit Managers, Pharmacies, and Health Plans From 2014 to 2018
Karen Van Nuys, Rocio Ribero, Martha Ryan and Neeraj Sood. JAMA Health Forum,November 2021.

In response to news stories and lawmakers’ inquiries into high insulin prices, the authors examine the flow of funds through the insulin distribution system.

They use data from the 2014 to 2018 regarding list and estimate net prices from the consulting firm SSR Health for 32 insulin products. They also consider information drawn from a commercial pharmacy claims database and mean acquisition costs and reimbursements from the Centers for Medicare & Medicaid Services, as well as data on spreads and rebates from state Medicaid and drug transparency reports.

They find that the mean list prices of 32 insulin products increased by 40.1%, from $19.60 to $27.45, between 2014 and 2018, while mean net prices earned by manufacturers decreased by 30.8%, from $10.53 to $7.29. The authors estimate that the share of insulin expenditures retained by PBMs increased by 154.6%, from $5.64 to $14.36.

Federal officials and companies have taken several steps in recent years to curb consumers’ out-of-pocket costs for insulin, with a shift that allows many insured patients to pay $35 per month for a necessary supply of the drug. These include a cap for costs for people on Medicare. But this approach leaves unaddressed the rising behind-the-scenes cost of insulin, which adds to rising total health costs.

The authors write: “While limiting beneficiaries’ [out of pocket] costs may provide immediate financial relief to insulin users, it does not fundamentally resolve the problem of increasing insulin costs, and such proposals could create more pressure on premiums to increase. Instead, we recommend a solution that addresses the root cause of increasing insulin costs, particularly addressing the roles played by distribution system intermediaries.”

Disadvantaging Rivals: Vertical Integration in the Pharmaceutical Market
Charles Gray, Abby E. Alpert and Neeraj Sood. NBER working paper, August 2023.

The authors of this working paper describe it as the first major study of the consequences of vertical integration between insurers and PBMs.

They focus on how the market changed following the 2015 acquisition of the last significant stand-alone PBM, Catamaran, by UnitedHealth, which already owned the giant Optum PBM. To conduct their research, the authors used datasets from the Medicare Part D plan for the year 2010 to 2018. They also used data from the consulting group Decision Resources Group.

Prior to UnitedHealth’s acquisition of Catamaran, between 2010 and 2014, the premium trends for health plans not affiliated with PBMs, or non-vertically integrated plans, were not statistically distinguishable from vertically integrated plans, or ones that are part of the same companies as PBMs.

The study finds that insurers that shifted to a rival’s vertically integrated PBM after using Catamaran experienced a premium increase of 22%, or approximately $12 a month, relative to a control group of vertically integrated plans, meaning health plans that were part of an organization that owns a PBM. For insurers already using a rival’s vertically integrated PBM in 2015, there was a 53% increase, or about $29.

This apparent benefit of switching to a vertically integrated PBM was perhaps due to economies of scale that could reduce costs, the authors write. Upon further investigation, they find the plans most directly affected by Catamaran’s exit from the market had a smaller premium increase, a counterintuitive result.

Since plans that previously used Catamaran tended to be larger insurers, the premium effects of the merger for these plans could be lower compared with the merger’s impact for smaller insurers. Smaller former Catamaran customers had a premium increase averaging closer to $40, supporting this thesis, the researchers find.

The authors also note that the loss of Catamaran may have prompted its former customers to do more diligent research in looking for new PBMs. Businesses will sometimes stick with their current PBMs instead of shopping around for new deals, as customer inertia in this field is known to keep health plans allied with PBMs. PBMs may have offered better deal terms to these health plans to attract new clients and then gradually increase cost over time as insurers become more inattentive, a strategy known as “invest-then-harvest” strategy, they write.

The authors write: “… regulators should carefully weigh the potential benefits of vertical integration with the potential for foreclosure. …A vertical merger can also reduce costs by improving the operational efficiency of the joint firm. However, regulators should also consider how increasing vertical integration caused by rising concentration of these firms, or even the removal of a non-integrated competitor, could increase the incentive for foreclosure which may offset potential efficiencies gained from the merger.”

Additional resources

Tools for tracking health care industry lawsuits

Georgetown’s Health Care Litigation Tracker is following the Lewandowski v. Johnson and Johnson lawsuit and similar cases. This open-access website provides clear short descriptions of cases, providing helpful introductions for the public to complex legal issues.

The well-respected SCOTUS blog is tracking the Mulready v. PCMA case.

Where to track congressional interest in PBMs

The House Oversight and Accountability Committee has shown a deep interest in the operations of PBMs, holding a series of hearings and producing the report, The Role of Pharmacy Benefit Managers in Prescription Drug Markets     .

At a July hearing, the committee called executives of the three largest PBMs to appear as witnesses. In testimony, the PBM executives maintained that they worked to lower drug prices, seeking to rebuff criticism of their role in fueling pharmaceutical price increases. They also maintained they support independent pharmacies.

Rep. James Comer (R-KY), the chair of the House Oversight and Accountability Committee, in September took the unusual step of sending letters seeking correction in testimony from all three witnesses at the June hearing: David Joyner, president of CVS Caremark; Adam Kautzner, president of Express Scripts and Patrick Conway, chief executive officer of UnitedHealth’s Optum Rx.

In these letters, Comer reminded the executives that they had testified under oath. The companies sent responses through their law firms, sticking by their testimony. In response, law firms representing the companies replied and maintained that no corrections were needed.

Other key congressional reports and hearings on PBMs include:

• U.S. Senate Committee on Commerce, Science, and Transportation. Bringing Transparency and Accountability to Pharmacy Benefit Managers. February 16, 2023.

• U.S. Senate Committee on Finance. Pharmacy Benefit Managers and the Prescription Drug Supply Chain: Impact on Patients and Taxpayers. March 30, 2023.
  

Tools for tracking pharmacy issues

The Associated Press created a tool for checking for pharmacy deserts in the U.S.

The National Community Pharmacists Association (NCAPA has a webpage that tracks efforts to change laws on PBMs.

The NCPA also this year released results of its survey of about 10,000 independent pharmacy owners and managers in February, getting about 815 responses. Of these respondents, 32% said they are considering closing their business within this calendar year, NCPA said.

Tools for tracking state-level legislative actions

The Columbus Dispatch’s reporting on PBMs helped spur Ohio officials to action on the changes it made to its Medicaid plans, a step that served as an inspiration to other states.

The Association of Health Care Journalists hosted a 2022 webinar with Darrell Rowland, the former Columbus Dispatch journalist, about this reporting.

The National Academy for State Health Policy has a web page where it tracks PBM legislation.

Industry groups to know

The Pharmaceutical Care Management Association (PCMA) is the trade group for PBMs.

America’s Health Insurance Plans (AHIP), a trade group that represents health insurers, has a web page about the benefits of PBMs.

Groups that have taken an interest in greater regulation of PBMs include:

• American Medical Association
• National Association of Chain Drug Stores
• Purchaser Business Group on Health (PBGH)

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Tip sheet:  4 things journalists covering PBMs should do

1. Reach out to independent pharmacies.

Journalists working on stories about PBMs should reach out to independent pharmacies in their coverage areas, says Rep. Earl “Buddy” Carter (R-GA), one of the experts on PBMs among members of Congress. He brings to his legislative work his experience from four decades working as a pharmacist, including owning Carter’s Pharmacy, Inc.

They should ask the owners of these businesses how much (or how little) they get paid by PBMs when they dispense drugs, Carter says. He also suggests journalists ask about the financial decisions PBMs reach through a process called adjudication, in which a pharmacy sends a patient’s claim electronically to a PBM, the PBM evaluates the claim, and then the PBM sends a response back to the pharmacy. Pharmacists can provide examples of the amounts they get from adjudicated claims of different medicines, Carter says.

“When my computer calls their computer and it calls back and says, ‘This is how much we’re going to pay you. This is how much you’re to charge the patient copay,”” Carter says, “all that information is right there via computer.”

Journalists can ask the independent pharmacies to provide examples of cases to show how low reimbursement is affecting them.

“The pharmacist will be glad to show them. ‘I sent this claim to the insurance company. This is how much they’re going to pay me. This is how much I paid for it. So I’m going to lose $3 on this drug right here,’ or `I’m only going to make 15 cents on this one’,” Carter says.

Journalists can remind audiences of the counseling pharmacists provide to patients. The staff of independent pharmacies sometimes can help patients avoid complications by emphasizing the need to take medicines correctly, such as making sure in some cases to accompany them with food or milk.

2. When reporting on pharmacy deserts, note that many factors are at play in pharmacy closings. 

Be careful not to imply that PBMs are solely responsible for the trend of pharmacy closures. Like other small businesses, these firms also face rising rent and labor costs, along with competition with online retailers, as journalists Reed Abelson and Rebecca Robbins explain in their Oct. 19, 2024 story in the New York Times, The Powerful Companies Driving Local Drugstores Out of Business.

“People have grown more comfortable getting everything from laundry detergent to medications delivered through the mail, sapping pharmacies of long-running revenue streams,” they write.

3. Ask questions about whether any given policy change proposal would lower drug costs for patients.

Although regulatory and legislative proposals are often promoted as measures meant to protect patients, these proposals are often driven by pharmacies and other interested parties aiming to weaken PBMs to advance their own interests, Ge Bai of Johns Hopkins University told The Journalist’s Resource in an e-mail exchange.

 “It’s essential for journalists to help the public understand whether a regulation would ultimately benefit patients,” she wrote.

Bai explores this question in a 2023 special communication article in JAMA Health Forum, titled Pharmacy Benefit Managers: History, Business Practices, Economics, and Policy.

Some researchers contend that stripping PBMs of their ability to profit through rebates would raise and not lower medical costs.

For example, Casey Mulligan, who served as chief economist for the Council of Economic Advisers in the first Trump administration, has said taking away rebates as a path to PBM profit would be a boon for drug manufacturers and retail pharmacy companies.

In a 2023 NBER working paper, Mulligan looked at what might happen if PBMs would receive fixed payments, regardless of the number of discounts they obtained from manufacturers and pharmacies. “Absent the financial incentives, plans would pay more to manufacturers and to pharmacies because plans would receive less manufacturer rebates and pharmacy discounts,” he writes.

Mulligan estimates the potential costs if PBM’s “pay for performance” compensation for Medicare were shifted to approaches claims to be tied to the list price of a drug. He writes that annual federal spending on Medicare Part D premiums would increase $3 billion to $10 billion if PBMs were blocked from making profits on the rebates and discounts they negotiate.

Mulligan notes the PBM trade group, the Pharmaceutical Care Management Association, compensated him for conducting this research on publicly available data, but did not have control of his findings. 

In a November set of recommendations for Congress, Jackson Hammond, senior policy analyst at the Paragon Health Institute, a conservative nonprofit think tank, urges against delinking PBM compensation from rebates. 

“Rebates are a negotiating tool that is widely used in our economy, and PBMs typically take only a small percentage of them, usually between 1 percent and 5 percent,” Hammond writes. “Taxpayers risk higher drug prices if PBMs lose incentives to negotiate the best prices for their client plan sponsors.”

Paragon’s president is Brian Blase, who was a special assistant to the president for economic policy at the White House’s National Economic Council (NEC) from 2017-2019, where he worked on health policies.

4. Check what your state and federal representatives have done and are doing — and how well it’s working.

The National Academy for State Health Policy is a good place to begin checking what local officials have done to address concerns about PBMs.

You can also see if members of Congress representing your audience have signed onto bills using Congress.gov and checking for “pharmacy benefit manager” legislation. In addition, you can check what actions your state attorney general has taken.