How CVS, Cigna, and UnitedHealth Control ...(Damn Near Everything)
The Middlemen Stealing Your Medicine Money
You walk into a pharmacy.
You hand over your prescription.
You get charged $300 for a pill that costs $3 to make.
You think: "This is insane. Someone's getting rich off my misery."
You're right.
And it's not your pharmacist.
Meet the Pharmacy Benefit Manager (PBM) cartel…three companies you've probably never heard of that control 80% of all prescriptions in America while skimming billions off every transaction.
This is the story of how CVS, Cigna, and UnitedHealth built the most profitable middleman scam in American history.
MEET YOUR DRUG DEALERS (THE LEGAL ONES)
Picture this: You're at a restaurant.
You order a steak.
But before it gets to your table, some asshole in a suit intercepts it, takes a bite, charges you $100, gives the restaurant $15, and pockets $85.
You'd flip the table, right?
That's EXACTLY what's happening every time you fill a prescription.
They're called Pharmacy Benefit Managers…PBMs.
And three companies control 80% of every prescription in America:
CVS Health owns → CVS Caremark (the PBM)
Also owns: CVS pharmacies, Aetna insurance
Cigna owns → Express Scripts (the PBM)
Cigna bought Express Scripts in 2018 for $67 billion
UnitedHealth Group owns → OptumRx (the PBM)
Also owns: UnitedHealthcare insurance, Optum health services
Never heard of them?
That's the point.
They generate a TRILLION DOLLARS while hiding in the shadows, and you're paying for their yacht collection every time you need medicine to stay alive.
HOW THE FUCK DID WE GET HERE?
Back in the 1960s, PBMs had one simple job: help process prescription paperwork.
Like a medical secretary.
Useful, but not exactly powerful.
But these clever bastards realized something: If you control the paperwork, you control the system.
It's like the secretary who starts reading the boss's emails, then answering them, then making decisions, and suddenly they're running the whole company while the boss wonders why nothing works anymore.
Except in this case, the "company" is whether you get your insulin, and the "boss" is every sick person in America.
THE SCAM SO BEAUTIFUL IT MAKES ME WANT TO PUKE
Here's how they rob you blind while looking like the good guys:
THE REBATE SHELL GAME
Let's say you need insulin.
Follow this money:
Drug company sets price: $300 (already bullshit, but stay with me)
PBM threatens drug company: "Nice insulin you got there. Be a shame if we didn't cover it. How about you give us a $200 'rebate' and we'll put it on our list?"
You show up at pharmacy: Your copay is 20% of $300 = $60. Insurance pays $240.
The magic trick: PBM collects that $200 rebate.
Do they give it to you?
To your insurance to lower premiums?
FUCK NO.
They keep it.
You just paid $60 for insulin that costs $3 to make, while the PBM made $200 for moving papers around.
And the kicker?
They do this 6.6 BILLION times a year.
That's not business.
That's a protection racket.
"BUT WAIT, THERE'S MORE!"…THE SPREAD PRICING SCAM
This one's so dirty I need a shower just thinking about it.
Your insurance company pays the PBM to "negotiate lower prices."
Here's what actually happens:
PBM bills your insurance: $100
PBM pays the pharmacy: $20
PBM pockets: $80
For doing WHAT exactly?
For being the middleman nobody asked for.
Real example that'll make your head explode:
CVS Caremark charged $3,930 for an MS drug.
They paid the pharmacy $177.
They kept $3,753.
That's a 2,122% markup.
FOR FORWARDING A PRESCRIPTION.
Bernie Madoff is in prison for less than this.
THE PART THAT SHOULD BE ILLEGAL BUT ISN'T
Each of these PBM fuckers owns EVERYTHING:
CVS owns:
The PBM (Caremark) that decides what drugs you can have
The insurance (Aetna) that decides what they'll pay for
The pharmacy (CVS) where you have to buy it
So CVS gets to:
Decide if your drug is covered (as your PBM)
Decide how much to pay for it (as your insurance)
Force you to buy it at their store (as your pharmacy)
Keep all the rebates (as all three)
It's like letting the casino own the bank AND write the gambling laws.
Actually, no…casinos are more honest than this.
THEY'RE LITERALLY KILLING YOUR PHARMACY
You know that nice independent pharmacy where they know your name?
Where the pharmacist actually talks to you about your meds?
It's going to close.
PBMs are murdering them:
The Hit: Force pharmacies to sell drugs for less than they paid
Pharmacy buys drug for $50
PBM reimburses $35
Pharmacy loses $15 EVERY TIME
The Burial: Mystery fees called "DIR fees" (Direct and Indirect Remuneration)
Charged randomly, months later
No explanation, no appeal
Increased 107,400% since 2010 (not a typo)
One independent pharmacy closes EVERY DAY.
Meanwhile, guess which pharmacies get paid properly?
The ones owned by PBMs.
THE INSULIN MURDERS
This is where I get genuinely furious.
The FTC finally grew some balls and sued all three PBMs for rigging insulin prices.
The evidence:
1999: Insulin cost $21
2017: Same insulin cost $274
2019: 1 in 4 diabetics couldn't afford their insulin
People DIED.
Rationing insulin.
In the richest country on Earth.
Why?
Because PBMs make more money on expensive insulin than cheap insulin.
They REFUSED to cover affordable versions.
They DEMANDED higher rebates on expensive brands.
They EXCLUDED cheaper options from formularies.
They chose profits over lives.
Repeatedly.
Systematically.
Knowingly.
If you did this to one person, it's murder.
They did it to millions, so it's business.
WHERE THE FUCK IS YOUR MONEY GOING?
Last year, PBMs collected $334 BILLION in rebates and fees.
That's $1,000 for every person in America.
Where did it go?
Lower drug prices? No.
Cheaper insurance? No.
Better healthcare? Fuck no.
It went to:
Executive bonuses
Shareholder profits
Lobbying to keep the scam going
Buying more politicians
CVS CEO made $21.6 million last year.
For what?
For standing between you and your medicine with his hand out.
THE TRUMP ADMINISTRATION CON JOB
Here's the beautiful hypocrisy:
Trump SAYS: "PBMs are horrible middlemen making more money than drug companies!"
Trump DOES:
Kills PBM reform in December 2024
Guts the FTC so they can't pursue the lawsuit
Appoints industry-friendly commissioners
He's literally protecting the people he claims to hate.
It's like declaring war on drug dealers while giving them police escorts.
THE POLITICIANS KEEPING YOU SICK
You want to know why this never gets fixed?
2023 PBM Lobbying:
PCMA (PBM trade group): $3.2 million
CVS Health: $3.8 million
UnitedHealth: $6.1 million
Cigna: $2.4 million
For that money, they buy:
Killed reforms
Friendly regulations
Protection from lawsuits
Your elected officials
Both parties take the money.
Both parties protect the scam.
Your suffering is bipartisan.
WHAT OTHER COUNTRIES DO (SPOILER: NOT THIS SHIT)
No other developed country has PBMs like ours.
They just:
Negotiate drug prices directly
Ban middleman markups
Require transparent pricing
Put patients before profits
Result: They pay 75% less for the same drugs.
But that would end the gravy train for our corporate overlords, so instead you'll keep paying $300 for $3 insulin while some executive buys his fourth house.
THE FIXES THEY'RE DESPERATE TO STOP
The solutions are embarrassingly simple:
Make PBMs pass through ALL rebates to patients
Your $200 insulin rebate? You get it, not them.
Ban ownership conflicts
Can't own the PBM, insurance, AND pharmacy
Pick one, assholes
Transparent pricing
Show the REAL cost, markup, and profit
No more secret rebates
Protect pharmacies
Minimum reimbursement rates
No surprise clawbacks
No steering to PBM-owned stores
Maryland did this for hospitals. Prices dropped 40%.
But PBMs spent millions ensuring it never happens for drugs.
HERE'S WHAT REALLY FUCKING GETS ME
Your pharmacist… is losing money filling prescriptions.
The drug company already made their profit.
Your insurance company thinks they're paying a fair price.
But between all of them sits this parasite, extracting $ for shuffling papers and denying coverage.
They produce NOTHING.
They heal NOBODY.
They help NO ONE.
They just stand between sick people and medicine with their hands out.
And they've gotten so rich doing it, they can buy enough politicians to make sure it never changes.
THE BOTTOM LINE
Next time someone tells you healthcare is complicated, remember this:
Three companies nobody's heard of are stealing $334 billion a year by standing between you and your pills.
That's not complicated.
That's theft.
And they're counting on you being too sick, too tired, or too broke to stop them.
Prove them wrong.
REFERENCES:
Every market share figure, profit calculation, and regulatory action detailed in this article is documented in official reports and government investigations.
MARKET CONCENTRATION DATA
Big Three PBM Market Share:
Drug Channels Institute, "The Top Pharmacy Benefit Managers of 2023: Market Share and Trends," 2024
CVS Caremark, Express Scripts, OptumRx control 79.8% of equivalent prescription claims
Federal Trade Commission Interim Staff Report, "Pharmacy Benefit Managers," July 2024
95% Market Control Finding:
FTC Press Release, "FTC Releases Interim Staff Report on Prescription Drug Middlemen," July 9, 2024
Six largest PBMs control 95% of US prescriptions through networks
Referenced in Pharmacy Times, "PBM Reform Takes Off in 2025," April 11, 2025
FTC INSULIN LAWSUIT (2024-2025)
Original Lawsuit Filing:
FTC Press Release, "FTC Sues Prescription Drug Middlemen for Artificially Inflating Insulin Drug Prices," September 20, 2024
Targets CVS Caremark, Express Scripts, OptumRx and affiliated GPOs
Allegations of "perverse drug rebate system" prioritizing high rebates
Insulin Price Data:
1999 Eli Lilly Humalog: $21 average list price
2017 same insulin: $274 (1,305% increase)
2019: 25% of insulin patients couldn't afford medication
All data from FTC administrative complaint
Case Status Updates:
Judge declined to halt case: Healthcare Dive, February 20, 2025
FTC halted case April 2025: Axios, "FTC halts case against CVS Caremark, OptumRx," April 3, 2025
Reason: No sitting commissioners able to participate due to recusals and firings
SPREAD PRICING EXAMPLES
CVS Caremark Multiple Sclerosis Drug Example:
Federal Trade Commission investigation findings, 2024
Charged plans $3,930, paid pharmacy $177
2,122% markup documented in FTC interim report
Generic Spread Pricing Research:
FTC findings: PBMs generated $7.3 billion in excess revenue from specialty generic drugs 2017-2022
Center for American Progress, "5 Things To Know About Pharmacy Benefit Managers," December 18, 2024
DIR FEES EXPLOSION
107,400% Increase (2010-2020):
Centers for Medicare & Medicaid Services data
RedSail Technologies, "The State of PBMs 2024 Report," January 10, 2024
Survey of 235 pharmacy professionals documenting impact
REVENUE AND FINANCIAL DATA
Company Revenue Figures (2023):
CVS Health: $357.8 billion (SEC filings, annual reports)
UnitedHealth Group: $371.6 billion (SEC filings, annual reports)
Cigna: $195.3 billion (SEC filings, annual reports)
$334 Billion Gross-to-Net Bubble:
Drug Channels, "PBM Power: The Gross-to-Net Bubble Reached $334 Billion in 2023," July 2024
Analysis of rebates, discounts, and price concessions flowing through intermediaries
PATIENT COST IMPACT
Additional Patient Costs:
Commercial patients pay $6 more per prescription due to PBM practices
Medicare beneficiaries pay $13 more per prescription
Committee for a Responsible Federal Budget, "PBM Reform on the Horizon," October 22, 2024
LEGISLATIVE REFORM FAILURES
Federal Reform Attempts (2024):
House passed Lower Costs, More Transparency Act (H.R. 5378) December 2023
Senate bills: MEPA (S. 2973), BETTER (S. 3430), PBM Reform Act (S. 1339)
Drug Topics, "PBM Reform Pulled Back in Late Change to Spending Package," December 20, 2024
State-Level Activity:
National Academy for State Health Policy: All 50 states have PBM legislation
2024: 24 states passed 33 PBM regulation bills
Pharmacy Times coverage of state-by-state reforms
VERTICAL INTEGRATION STRUCTURE
CVS Health Integration:
Owns CVS Caremark (PBM), CVS pharmacies, Aetna insurance
FTC analysis of vertical integration impacts on competition
UnitedHealth Group Integration:
Owns OptumRx (PBM), UnitedHealthcare insurance, extensive provider networks
Senate investigations into vertical integration effects
Cigna Integration:
Owns Express Scripts (PBM), Cigna insurance, Evernorth health services
Congressional oversight committee documentation
INDUSTRY PUSHBACK AND LAWSUITS
Express Scripts Lawsuit Against FTC:
Filed September 17, 2024, demanding retraction of FTC report
Modern Healthcare, "Express Scripts sues FTC over PBM report," September 17, 2024
Claims FTC report is "false, misleading, and harmful"
PBMs' Constitutional Challenge:
Filed November 2024 claiming FTC process is unconstitutional
Modern Healthcare, "OptumRx, CVS Caremark, Express Scripts sue FTC," November 19, 2024
LOBBYING EXPENDITURES
2023 Lobbying Spending:
PCMA (Pharmaceutical Care Management Association): $3.2 million
CVS Health: $3.8 million
UnitedHealth Group: $6.1 million
Cigna: $2.4 million
OpenSecrets.org lobbying disclosure database
INDEPENDENT PHARMACY IMPACT
Pharmacy Closure Data:
National Community Pharmacists Association (NCPA) tracking
One independent pharmacy closes daily due to PBM practices
Rural pharmacy access impact studies
Below-Cost Reimbursement Documentation:
NCPA surveys showing reimbursement below acquisition costs
State pharmacy board complaints and documentation
Academic studies on pharmacy viability under PBM contracts
TRUMP ADMINISTRATION POSITIONS
Trump Quotes on PBMs:
"Horrible middleman that makes more money, frankly, than the drug companies"
News conference statements December 2024
Drug Topics coverage of administration position changes
Policy Actions:
Removal of PBM reform from December 2024 federal funding package
FTC case halt April 2025 due to commissioner changes
Executive order actions affecting PBM regulation
INTERNATIONAL COMPARISONS
Global PBM Analysis:
Commonwealth Fund international healthcare system comparisons
OECD health data on pharmaceutical pricing mechanisms
Academic research on international drug pricing models
Price Comparison Studies:
Americans pay 2-4x more for same drugs vs international markets
RAND Corporation international prescription drug price comparisons
PATIENT ACCESS IMPACTS
Mail-Order Mandates:
Consumer Reports investigations into forced mail-order requirements
Patient advocacy group documentation of access barriers
Specialty Drug Steering:
FTC analysis of specialty drug definitions and patient steering
Academic research on specialty pharmacy network restrictions
REGULATORY CAPTURE EVIDENCE
Industry-Government Revolving Door:
Analysis of former regulators joining PBM industry
Public Citizen reports on regulatory capture
Congressional oversight committee findings
CONGRESSIONAL INVESTIGATIONS
House Oversight Committee Investigation:
Committee for a Responsible Federal Budget analysis of over 140,000 PBM documents
House Oversight and Accountability Committee hearings July 2024
Chairman James Comer statements on PBM CEO testimony
Senate Finance Committee Work:
Modernizing and Ensuring PBM Accountability Act development
Bipartisan PBM reform legislation documentation
This is 💯 correct. A sad reality. I'm choosing to live a healthy lifestyle and have stopped using the so called "healthcare" system. It's just a money scheme that leverages people's fear.
The word greed doesn't describe this. It implies that there is a limit at some point to what even the most blackhearted bastards will steal. And thank you, government of the people, by the people, and for the people. Where are our new revolutionarries? Where?