12/12/2025
A Call to Action: Defending Your Healthcare Rights Against PBM Monopoly
To Our Fellow American Residents,
We must urgently realize and exercise our fundamental right to choose our doctor, our pharmacy, and our therapy. We cannot allow large insurance companies and their affiliated Pharmacy Benefit Managers (PBMs) to monopolize our healthcare decisions, potentially compromising patient safety and treatment efficacy for the sake of corporate profit.
1. Erosion of Patient and Provider Choice
PBMs—acting as powerful intermediaries—are increasingly implementing policies that restrict choice:
• Mandatory Mail-Order/Exclusive Networks: Insurance plans are often structured to steer patients toward PBM-owned mail-order pharmacies (e.g., CenterWell, Express Scripts, CVS Caremark, and Optum pharmacies). This often happens without the patient's explicit consent. For instance, in many plans, critical, often acute, medications like antibiotics that require immediate initiation may be automatically routed to a distant mail-order facility, introducing unnecessary and dangerous delays.
• "Steering" Prescriptions: Prescribers sometimes face internal pressure or system defaults that automatically direct prescriptions away from local, independent pharmacies. This is a direct infringement on the patient’s right to choose the most convenient and trusted dispensing provider.
2. Patient Safety and Medication Integrity (The Cold Chain Issue)
The physical safety of your medication is compromised by mandatory mail-order policies:
• Temperature Excursion Risk: Most pharmaceutical labels clearly stipulate storage conditions, often between 56°F - 77°F. When medications are shipped across the country via standard carriers (UPS, FedEx) in non-climate-controlled environments, especially through high-temperature states like Arizona or during extreme seasonal weather, they are highly susceptible to temperature excursions. This heat exposure is known to degrade the chemical stability, potency, and efficacy of medications, rendering them less effective or even unsafe.
• Adherence Failures: Delays in mail-order shipping are a documented cause of non-adherence. Patients often report going to local pharmacies with empty bottles, having missed medication for a week or more while waiting for a delayed shipment. For therapies where adherence is critical (e.g., blood pressure, diabetes, mental health), this delay can lead to an emergency room visit or hospitalization, a costly outcome that undermines the PBM's goal of saving money.
3. The Illegal and Unethical Practice of Co-pay Manipulation
The core mechanism PBMs use to coerce patients is financial:
• Tiered Pricing/Co-pay Discrepancy: It is now common for PBMs to charge patients significantly higher co-pay at their local, community pharmacy, while simultaneously offering a lower co-pay, or even a $0 co-pay, at their own mail-order facility.
• Violation of Statute: This coercive pricing model is challenged as a predatory tactic that limits fair competition and patient choice. Critics argue this practice violates the spirit, if not the letter, of anti-trust principles and other established rules designed to protect free market competition and consumer rights.
4. Financial Waste and Political Influence
The practices of PBMs are linked to massive waste of public funds and political corruption:
• Non-Stop Shipping and Waste: Mail-order services frequently ship refills automatically and continuously, regardless of whether the patient actually needs the medication yet. This leads to substantial amounts of unused medicine accumulating in homes and ultimately results in the wastage of taxpayer money from programs like Medicare and Medicaid.
• Lobbying Power: PBMs are colossal corporations with significant political influence. They actively lobby legislators and contribute heavily to political campaigns, which critics argue is a form of "kickback" that allows them to maintain their opaque and detrimental business model, stifling reform that would benefit patients and taxpayers.
For example, some states have explored Direct Provider Reimbursement models (similar to certain aspects of the Texas Medicaid system), which could eliminate the PBM middleman and, according to various estimates, significantly cut the state's prescription drug budget. The fact that this obvious cost-saving measure is often blocked highlights the powerful bureaucratic and political opposition funded by PBM interests.
What You Must Do Now
It is time to wake up and demand accountability. Your right to choose your healthcare providers is under threat.
Demand transparency, oppose mandatory mail-order schemes, and insist that your co-pay be the same regardless of whether you choose your local pharmacy or a PBM-owned one. Do not encourage this illegal and unethical practice, or you and your future generations will suffer the consequences of a profit-driven, monopolized healthcare system.
The Real Payer: Your Taxes and Social Security Fund Your Care
To all beneficiaries and citizens: It is crucial to dispel the myth that insurance companies, including those that manage Medicare and Medicaid drug benefits (PBMs), are providing a "free service." They are not.
The plans that manage your care are paid through massive public expenditures derived from taxpayer money. This fact is the ultimate foundation for your right to demand quality and choice.
1. Who Actually Pays the Premium?
Program The Real Payer Financial Reality
Medicare (Federal) Federal Government (through general revenue and dedicated payroll taxes) pays the bulk of the premium for most beneficiaries. The government often pays about 75% of the Medicare Part B premium. Insurance companies and PBMs are recipients of taxpayer funds. They receive large, government-backed premiums to administer your benefits. If they don't receive these funds, the coverage ends.
Medicaid (Joint Federal/State) Federal Government (with the Federal Medical Assistance Percentage, or FMAP) and State Governments (through state taxes) jointly finance and administer this program. States pay the premiums to Managed Care Organizations (MCOs), which often own or contract with PBMs. For dual-eligible and low-income Medicare beneficiaries, State Medicare Savings Programs (MSPs) pay the Part B and sometimes Part A premiums directly to the federal government. This means the state is paying the premium on your behalf.
The bottom line: The services are paid for with a combination of your past and present payroll taxes, Social Security deductions, and general state and federal tax revenue.
2. The Right to Choose is Non-Negotiable
When your tax dollars—collected by federal and state governments—are being paid to private insurance companies and PBMs, these entities have an obligation to provide benefits without compromising patient health or basic consumer rights.
The core issue is accountability:
• PBMs and their affiliated plans are paid a premium to manage your care. They are not volunteers.
• A fundamental right of any insured individual is the ability to choose their provider. This principle ensures competition, access, and accountability.
• When PBMs use coercive tactics (like forcing mail-order use through tiered co-pays) or restrictive policies (like narrow pharmacy networks), they are essentially compromising the services for which the government—and thus, the taxpayer—has already fully paid.
We must recognize that the PBMs' push toward mandatory mail-order is not a cost-saving measure for the taxpayer, but often a revenue-generating measure for the PBM itself, sometimes resulting in:
• Higher drug waste (due to auto-shipping).
• Compromised efficacy (due to heat-related degradation during shipping).
• Higher costs down the line (due to missed doses leading to emergency hospitalization).
Do not surrender your right to choose your doctor and pharmacist. This choice is not a luxury; it is a critical safeguard for your health and the responsible use of public funds.
