Pharmacy Stan

Pharmacy Stan PBMs are engineered to take your profit. I build the software that takes it back. | Founder of TheRxOS

05/15/2026

PBMs this month: "Trust us guys. We're doing transparency now."
Also PBMs this month:

Suing Arkansas becuase the state tried to stop them from owning pharmacies.

You cannot make this up.

CVS.
Express Scripts.
Optum.

Three corporations controlling roughly 80% of prescription claims are now rolling out "transparent" models while simultaneously fighting legislation aimed at breaking up the exact conflicts driving pharmacy closures in the first place.

AR passed a law saying PBMs cannot own retail and mail-order pharmacies starting in 2026.

And suddenly the free market crowd discovered govt overreach.

Amazing timing.

These companies spent years:
Reimbursing independant pharmacies below acquisition cost.
Steering patients into their own pharmacies.
Controlling formularies.
Controlling claims.
Controlling reimbursement.
Controlling the insurance plans.

Meanwhile nearly 1 in 3 independent pharmacies closed between 2010 and 2021.

Over 80% of prescriptions are now reimbursed below the average cost to dispense according to NCPA benchmarks.

Rural communities are losing pharmacies entirely while PBM-owned specialty and mail-order channels keep expanding.

Now they're deeply concerned about competition.
What a coincidence.

Healthcare has reached the point where the referee owns the team, sells the tickets, controls the scoreboard, and then launches a PR campaign about "fairness."

And we're all supposed to applaud the word transparency like it fixes anything.

Transparent about what exactly?
The spread pricing?
The rebate flow?
The patient steering?
The clawbacks?
The ownership conflicts?

The fact that the three largest PBMs generated $100s of BNs in combined revenue while healthcare costs keep climbing for everyone else?

The largest PBMs made record profits while Americans borrowed an estimated $74 billion last year just to pay medical bills.

States are finally starting to realize the issue was never a lack of PR.
Arkansas passed the first law banning PBM ownership of pharmacies. CVS,

Express Scripts, and Optum immediately challenged it in court.

Tennessee just passed the FAIR Rx Act targeting PBM vertical integration and pharmacy ownership conflicts.

AZ, OK, NJ, NY, TX, LA, and others all have active reform efforts moving through legislatures right now.

This is what actual pressure looks like.

Not another rebrand.
Not another corporate explainer video.
Not another executive LinkedIn post about "aligning incentives."
If you actually want reform:

Call your state legislators.
Ask who sits on the insurance and health committees.
Send them closure data from your community.
Draft legislation modeled after Arkansas or Tennessee.
Find one sponsor in the House.
Find one sponsor in the Senate.
Force the conversation into the open.

PBMs have armies of lobbyists in every capitol already.
Independent healthcare has pharmacists, physicians, patients, and business owners, it may not be fair - but it is what we have.

05/05/2026

For every $1 CVS Health paid in fines, an estimated $12 to $58 was stolen from taxpayers.
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That is not a guess. That is documented across 32 years of DOJ settlements, state AG actions, FTC consents, and HHS-OIG recoveries.
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Total fines since 1994: $5.83 billion. Omnicare kickbacks. Caremark false claims. Aetna upcoding. Oak Street kickbacks. Opioid dispensing. The $5 billion multistate opioid settlement. All of it.
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Damages documented in DOJ complaints and state audits: $74 billion to $340 billion.
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Damage-to-fine ratio: 12.7x on the low end. 58.4x on the high end.
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The public lost $12 to $58 for every dollar the government recovered.
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If I steal $100 from a bodega register, get caught, and the state fines me $7, I am running that play every single day. It is no longer a crime. It is a business model.
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That is the math CVS is running. At scale. Across 32 years.
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Look at Omnicare. CVS's long-term care pharmacy. Five separate federal kickback settlements since 2009. Five times the government said stop. Five times they paid and kept going. Total of all five settlements: $262 million.
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CVS Health makes $262 million in roughly six hours of revenue.
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Six hours. For five kickback cases spanning nine years.
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That is not accountability. That is a rounding error on a Tuesday.
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This is why the behavior does not stop. This is why reimbursements are upside down. This is why the same three PBMs control 80% of claims. This is why insulin cost what it cost for a decade.
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And this is just the documented stuff. It does not include whistleblower cases still sealed. It does not include the 46 state Medicaid programs that identified spread pricing but have not recovered a dollar. The real ratio is worse.
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Fines are not deterrents at these ratios.
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They are pricing signals.
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Real accountability is disgorgement plus treble damages. Individual executive liability. Exclusion from federal programs after repeat violations. The same standard any pharmacy tech faces for one mistake.
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If you are a lawmaker, that is your problem to fix. If you are a pharmacy owner, that is why your margins are gone. If you are a patient, that is why your drugs cost what they cost.
​
The math is doing exactly what it was designed to do.

04/20/2026

A Kansas pharmacy owner tried to fill his own chemo prescription at his own pharmacy.
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Claim denied.
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The drug was on the shelf. The pharmacist was him. The patient was him. The plan sponsor paying the insurance bill was him.
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His PBM still said no.
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His name is Mike Burns. AuBurn Pharmacy. Six years ago he heard three words nobody wants to hear. His doctors prescribed capecitabine. Oral chemo. OptumRx was the PBM.
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Rejected.
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"Specialty drug. Must go through specialty pharmacy."
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The specialty pharmacy had a contract with OptumRx. What a coincidence.
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The specialty pharmacy charged his plan $15,300 for six months of chemo.
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His own pharmacy would have filled it for $2,300.
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$13,000 of extra cost on one script. None of it bought him a minute of care. Nobody from the specialty pharmacy called him. Nobody counseled him. Nobody explained a single side effect of the "complex" therapy they claimed he wasn't qualified to handle.
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They shipped the box and cashed the check.
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That is the part that should end careers.
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"Specialty" is not a clinical designation. It is a pricing lever. A marketing term PBMs invented to carve out the highest-margin scripts and run them through their own buildings.
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Then the story turned.
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He did not shut up and take it. He testified in front of the Kansas Senate. Documented every dollar. Named every company.
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On April 9, Governor Laura Kelly signed Kansas SB 20.
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Bans spread pricing. NADAC plus a $10.50 dispensing fee floor. Rebate pass-through. Audit protections. 32-8 Senate. 104-17 House. Bipartisan and not close.
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Kansas passed that bill because a cancer patient stood in front of his legislators and told them what a PBM did to him while he was fighting for his life.
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Stories are how laws get written in 2026.
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Mike Burns is not rare. His case is standard operating procedure. Every independent has a version. Every self-insured employer has one sitting in their claims data and doesn't know it yet.
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If you have one, write it down. Send it to your state AG, your legislators, your state pharmacy association.
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Senator Roger Marshall demanded a TRICARE audit of Express Scripts yesterday at the Senate HELP hearing. He did it because Kansas pharmacists walked into his office with the same story over and over. Stories add up.
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Six to ten pharmacies close every day in this country. The Big 3 control 80% of all prescription claims. The federal reform Congress passed in February does not take effect until 2029.
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The states are the only ones fighting in real time. Kansas showed up. Tennessee is on the brink. Louisiana is reviving. Mississippi is weighing a special session. Pennsylvania rallied at the Capitol on Tuesday.
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The playbook works. One pharmacist with a story. One committee hearing. One bill. One governor with a pen.
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If you own a pharmacy, your story is not too small.
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It is the whole fight.
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Tell it.

Repeat after me, there is no shortage of healthcare professionals.There is no shortage of healthcare professionals.The o...
04/25/2023

Repeat after me, there is no shortage of healthcare professionals.

There is no shortage of healthcare professionals.

The only shortage that exists is a healthcare system that values patients and clinicians over profits.

A shortage that abysmal leadership, c suites, and board of directors created.

Maybe clinicians being told how to do clinical work poorly to squeeze out bigger bonuses for non clinical staff is simply the issue.

04/20/2023

3 Laws that would really shake things up in the pharmacy world:

1. Reimbursement on drugs to pharmacy may not be less than the pharmacy's cost paid to the wholesaler.

2. All pharmacies registered with the board of pharmacy must have 51% of its ownership vested in an actively licensed pharmacist.

3. Board of Directors/Executive Leadership must be 51% or more medical professionals in the healthcare field with first-hand experience practicing on the front lines.

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Regarding reimbursement:

Pharmacys will be reimbursed the cost plus x% with a minimum dispensing fee of $12.00 that is to increase with inflation to cover the bare minimum costs to dispense a prescription.

Regarding ownership:

Similar ownership laws exist in North Dakota already. There are only a few chains that were grandfathered in that exist now.

The same rules should apply up the corporate structure to ensure that healthcare companies are directed by healthcare professionals with relevant and active experience in the field.

Patients deserve better than being treated as dollars and cents on a spreadsheet.

- - -
Comment below with what laws you would add and hit that follow button for more pharmacy discussion on semi random basis.

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