INtroTUITION

My wife and I own a pharmacy. Last month we spent days trying to pry one prescription loose from a company that did everything it could to hold onto it. The drug was everolimus. A generic. It treats cancer and protects transplant patients from rejecting their new organ. Not exotic. Not rare. A pill. The patient wanted it filled with us because we're cash-pay and cost-plus. No insurance. No PBM. No secret markups, no games. Our price was $318. That's not cheap by our standards — most of what we fill runs under $20 — but it was honest. Here's what that same prescription looked like on the other side of the counter. In 2023, Medicare was paying about $6,645 for it. That's roughly 21 times our price for the identical medication. Medicare spent around $240 million on everolimus alone that year. If they'd paid our price, they'd have saved roughly $230 million. On one generic drug. So how does an insurance company profit off a drug that expensive? Don't they pay for it? No. You pay for it. In your premiums. Their job isn't to spend less — it's to keep your healthcare dollars circulating inside their own companies. And the tool they use is called spread pricing. Spread pricing works like this: the middleman bills the health plan one price, pays the pharmacy a lower one, and keeps the difference. You never see it. On TRICARE, they pay an independent pharmacy like mine about $311 to fill everolimus. That barely covers our cost of the drug. Meanwhile the plan gets billed thousands. That gap — north of $6,000 on a single fill — is pure margin the middleman pockets. Now here's the part they'd rather you not think about. The pharmacy we were fighting was Accredo. Accredo is owned by Express Scripts. Express Scripts is the pharmacy benefit manager owned by Cigna. Same company, three masks. That nesting-doll structure isn't an accident — it's the whole design. When the pharmacy, the PBM, and the insurer are all one entity, they can shuffle money between their own pockets and call it whatever they want. The confusion is the product. And this isn't a story about one weird drug. It's the business model. The FTC has been digging into exactly this. In its January 2025 report on the three biggest PBMs — CVS Caremark, Express Scripts, and OptumRx — staff found those companies marked up specialty generic drugs by hundreds and thousands of percent when dispensing through their own affiliated pharmacies. Just those markups generated more than $7.3 billion above what the drugs actually cost to acquire, from 2017 to 2022. One in five of the specialty generics they studied was marked up over 1,000%. Some cancer generics: over 3,000%. On top of that, the FTC pegged spread pricing on those same drugs at another $1.4 billion. One example straight from the FTC's files: dimethyl fumarate, a multiple sclerosis drug. Costs about $177 to acquire. The PBMs paid their own pharmacies close to $4,000 for a 30-day supply. Same trick. Different drug. And they steer the profitable ones to themselves on purpose. Pharmacies affiliated with the big three took in 68% of specialty dispensing revenue in 2023 — up from 54% in 2016. The prescriptions marked up more than $1,000 disproportionately end up at their own pharmacies, not independents like mine. So when we called to transfer this patient's everolimus to be filled without insurance, it landed like we were asking them to set $6,000 on fire. Of course they stonewalled us. That's why we fired them. No insurance means no invisible $6,000 charge buried in a premium you can't itemize. It means the price you see is the price. Ours was $318. Theirs was thousands. Same pill.