PBM Middlemen Are Still Winning — And Alabama Patients Are Still Losing

By Dr. B.J. Jones

Recent legislation in Alabama was designed to rein in the unchecked power of pharmacy  benefit managers (PBMs), but patients and independent pharmacies across the state are  still paying the price due to PBM influences. 

PBMs claim they manage prescription drug benefits and lower costs. Instead, they’ve  evolved into powerful, profit-driven middlemen that insert themselves between patients,  pharmacies, and drug manufacturers. Today, they operate with little transparency, dictate  which medications patients can access, and determine how much pharmacies are paid — often below cost. 

Pharmacists feel an innate responsibility to take care of their patients. So much so, they  often still provide care despite a financial loss. If you have ever been told “we can’t get that  drug” or “you must use a special pharmacy,” your local pharmacist was likely under siege of a gag clause or other unfair PBM mandate. 

A new coalition, the Alabama Independent Pharmacy Alliance (AIPA), led the grassroots  charge to fight back. Their work pushed lawmakers to pass legislation aimed at curbing  PBM abuses. This landmark reform was a huge win for patients and small businesses; However, the fight is far from over.  

SB252 was signed into law on April 15, 2025. More than 90 days later, PBMs are still skirting  regulations and continuing their profit-driven practices. Alabama’s independent  pharmacies — often the only source of medications in rural communities — are still closing  their doors. Others are barely surviving, with reimbursement rates so low they can’t afford  to keep life-saving medications on their shelves. The law is supposed to bring higher payments to pharmacies on October 1, but with PBMs already non-compliant to the early 

provisions of SB252, there is concern these middlemen may not submit to what lawmakers  have enacted. 

This isn’t a partisan issue. It’s a matter of access, fairness, and common sense. 

PBMs decide which medications are “preferred,” even when more affordable or effective  alternatives exist. They steer patients away from local pharmacies and toward mail-order  companies they own. They retroactively claw back payments from pharmacies weeks or  months after prescriptions are filled. These practices would be unthinkable in almost any  other industry. 

These tactics don’t just hurt small businesses; they harm patients. When a local pharmacy  closes, the next closest one might be 20 or 30 miles away. Elderly patients, those without  transportation, or families managing chronic illnesses are left with fewer options, longer  waits, and rising out-of-pocket costs. 

If you think this sounds like a monopoly, you’re not wrong. Three PBMs, CVS Caremark,  Cigna (Express Scripts), and UnitedHealth (Optum), control over 80% of the market.  UnitedHealth is number 4 on The Fortune 500 and all 3 are located in the top 16. Their  practices directly affect what medications are available, how much they cost, and whether  your local pharmacy can afford to stay open. Blue Cross of Alabama controls approximately 86% of the commercial prescription drug market in the state. 

So where do we go from here? 

First, we must tighten enforcement of the laws. Regulators must be empowered and willing  to hold PBMs accountable. From conversations with AIPA, it appears the Department of  Insurance is gearing up to do so. A strong stance from the Attorney General is now needed. 

What is his position? The inquiry has been made and is awaiting a reply.

Second, Alabama citizens should support and strengthen groups like AIPA, which continue  to fight this battle every day. They take zero salaries and implement transparent practices.  This isn’t a corporate lobbying group; it’s a coalition of everyday pharmacists and business  

owners who have banded together out of necessity to protect their patients and their  communities. 

Third, we need more transparency. PBMs should be required to disclose how much they  make, who’s profiting from their decisions, and be held accountable for how their actions  impact pharmacies and patients alike. 

At a time when healthcare costs are skyrocketing and rural healthcare access is shrinking,  we can’t afford to let profit-driven middlemen call the shots. PBMs have spent millions  convincing the public they save us money, but if you ask the hundreds of independent  pharmacists in Alabama — or the patients they serve — you’ll hear a different story: PBMs  are making healthcare worse, not better. 

The movement that began with AIPA has shown what’s possible when regular people stand  up to entrenched power, but the job isn’t finished. With continued pressure from citizens  and lawmakers that are not fooled by corporate spin, Alabama can lead the way in restoring fairness, access, and integrity to the pharmacy system.

B.J. Jones is a graduate of Samford University and owns 2 independent pharmacies in Northeast Alabama. He  is one of the founders of AIPA and a member of the AIPA Executive Board. He has practiced pharmacy for over  20 years and advocates for healthcare, small business, and small government.