Your Doctor Said Yes. Your Insurance Company Said No. Here's Why.

What if insurer middlemen stood between you and a life-saving medication? This is the case for far too many Americans.

Brandon was a 52-year-old accountant from Texas diagnosed with stage III colon cancer. He battled it into remission - until it came back at age 56. His community oncologist prescribed an oral chemotherapy designed for patients in his situation.

His prescription was sent to a specialty pharmacy. That pharmacy couldn't fill it and passed it to a second. The second passed it to a third. The third sent it back to the first. Back and forth it went while a man with metastatic cancer waited for a medication his doctor had already prescribed. Not one pharmacy called to explain what was happening.

Tragically, Brandon died while waiting for his medication.

His doctor said yes. The system never answered.

Brandon's case is one of dozens documented by the Community Oncology Alliance series The Real-Life Patient Impact of PBMs. These stories paint a picture of a system that routinely fails patients at their most vulnerable moments.

It would be easy to look at Brandon's story as a bureaucratic breakdown. A few dropped calls or administrative confusion. However, this is not the case.

Across America, patients with cancer, diabetes, autoimmune diseases and thousands of other conditions face the same trap. Their doctors prescribe the treatment tailored for their needs, but their insurance company – or the middleman working on its behalf – say no, not yet, try something else first, fill it here, wait for approval, start over.

Many patients give up. Many can't afford to wait. Some, like Brandon, run out of time.

Why? Because vertically integrated health insurers and their affiliated PBMs can benefit from this convoluted system.

PBMs sit between your insurance plan and your pharmacy. They decide which drugs are covered, how much you pay at the counter and which pharmacies you're allowed to use. Just three PBMs control nearly 80% of all U.S. prescription drug claims – and each is owned by one of the nation's largest health insurers. UnitedHealth Group, CVS Health and Cigna together control the insurance plan that covers you, the PBM that decides what you can access, and in many cases, the specialty pharmacy where you're required to fill your prescription.

PBMs are estimated to pocket $100 billion annually through practices like spread pricing and keeping drug rebates for themselves. PBM-affiliated pharmacies now control 68% of specialty drug dispensing revenue – and have marked up specialty generic drugs by more than 1,000%. Meanwhile, more than 1,000 independent pharmacies closed in 2024 alone, making it harder for patients in communities across the country to access their medications.

Too often prescriptions are bounced between specialty pharmacies with no resolution and no accountability – moving through a system built by these same vertically integrated giants who have every incentive to protect its own margin and no obligation to the patient waiting on the other end.

Prior authorization, step therapy and narrow formularies were originally designed as cost-control tools. Today they function as barriers – generating delay and frustration while insurers and PBMs steer patients toward drugs and pharmacies that maximize internal profit. Forty-two cents of every dollar spent on brand-name drugs now flows to PBMs in the form of rebates and fees that rarely make it back to patients or employers.

When a doctor says yes and the system says not yet – patients lose. No patient should die waiting for a medication their doctor prescribed.

Meaningful reform – transparency, accountability and an end to the conflicts of interest that put corporate profits above patient care – is within reach. It is time to put patients first. Learn more about policy solutions here.