Advocates have been trying to pass pharmacy benefit manager reform in Missouri for years.
These benefit managers serve as the middlemen between insurance companies, drug manufacturers and pharmacies to help negotiate drug costs and manage benefits for patients.
Critics say the system needs an overhaul: Prescription costs are rising, independent pharmacies are closing in communities across the country and many PBMs are owned by large health care systems that also control insurance companies and national pharmacy networks.
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Despite success in Kansas, Missouri’s latest rendition of PBM reform failed in this spring’s legislative session. The legislation would have strengthened state oversight of PBMs to help improve patient costs and support independent pharmacies. Previous bills had a habit of dying in the Senate, if they made it to the chamber in the first place.
It’s the seventh year in a row PBM reform has failed in Missouri.
In Arkansas, legislation to ban anti-competitive practices for PBMs was signed into law in 2025. Missourian Loretta Boesing traveled there to testify in support of Arkansas’ legislation last year. Boesing, the Arkansas Pharmacists Association’s Patient Advocate of the Year, has been speaking up for patients since 2018.
“I don't want to see another year go by and changes not being made at the state and federal level. We need more to protect them,” Boesing said. “I can't rest.”
Boesing’s son Wesley went into transplant rejection after taking mail order drugs that had been left in the Missouri heat. Boesing’s insurance had directed the family to its PBM-owned mail order pharmacy. She says it is still a fight to get Wesley’s medications filled in person at her local pharmacy.
State Rep. John Hewkin, a Republican from Cuba and a pharmacist for nearly four decades, was the primary sponsor of the Missouri House’s PBM regulation bill.
The freshman legislator with 19 grandchildren spent much of his first year in office analyzing why PBM legislation keeps failing.
“I wouldn’t believe when I ran for office that you could have a problem that you could write legislation for, and the very people who caused the problem, you have to negotiate with,” Hewkin said.
He’s been on both sides, having owned an independent pharmacy and working for PBM-owned chains like CVS.
“I'm not saying that (PBMs are) terrible. … What this bill backs up is that the way they audit the pharmacies is unfair, the way they pay the pharmacies is unfair, the contracts are unfair. We've got to do something to fix that,” Hewkin said.
Some see savings with PBMs
The Mid-America Carpenters Regional Council and the Missouri Chamber of Commerce spoke against the proposed Missouri legislation.
Mark Dalton, the union’s Missouri political director, said that the union’s current setup allows cost savings to flow into a fund that allows the union to lower overall plan costs. The legislation would have let cost savings flow directly to the patient.
“On the surface, it sounds great to save money for the individual that is filling the prescription, but in a plan like ours, we give those discounts back to our health and welfare fund so that it is spread out evenly amongst all of our members and their family that are covered on our plan,” Dalton said.
In February, Congress passed federal PBM reform as part of its appropriations act. It aims to lower costs for medications and preserve healthcare access. Medicare, which also uses PBMs to manage drug benefits, will be provided funds to investigate pharmacies’ complaints of PBM mistreatment under the law.
Implementation of the federal reform will take at least two years.
“Sadly, it's not going to be near soon enough for the majority of pharmacies that are already struggling,” said Mike Burns, owner of the AuBurn Pharmacy chain.
Before the federal change, Cigna, the major healthcare organization that owns pharmacy benefit manager Express Scripts, announced that the company was debuting a new PBM model that aims to help lower drug costs for patients.
“Our new pharmacy benefit model was built to strengthen community pharmacy viability by reimbursing pharmacies based on their actual drug acquisition costs and paying more for the clinical services pharmacists provide every day, from medication counseling to health screenings,” a spokesperson from Express Scripts said.
Independent pharmacists such as Abe Funk aren’t convinced the changes will help long term.
“I can't afford a full-page spread in the Wall Street Journal, but two or three times a week, there's a full page of the back of the Wall Street Journal with Express Scripts talking about how good they do for healthcare for everybody,” Funk said. “What we found is that when they say they're going to change this piece, they just come in and manipulate somewhere else.”
'We'll have to fight for them'
The Federal Trade Commission, under both the previous and current presidential administrations, has recognized that as pharmacy benefit managers merge with other areas of healthcare, patients are paying more and independent pharmacies lose the leverage to negotiate reimbursements.
The FTC and Express Scripts settled a lawsuit in February, in which the FTC alleged Express Script’s conduct artificially inflated insulin drug prices.
Before the settlement, Express Scripts had filed a lawsuit against the FTC for its July 2024 report on the PBM industry, alleging false and misleading claims about benefit managers in the report.
“The PBM is designed to force down the cost of the drugs, and they do that by leveraging volume and saying, ‘We represent all these lives.’ If you want your drug covered on these plans, you need to offer a better deal to our clients,” said Phil Christofanelli, who represents 20 pharmacy benefit managers through the Pharmaceutical Care Management Association.
That kind of concentration can give larger benefit managers more leverage but can hurt smaller players in the process.
Not all patients see a downside: Bill Rhoads walked into AuBurn’s Camdenton location holding his wife’s OptumRx benefits card that would pay for his baking soda tablets and insulin pen needles.
“It’s very beneficial. Very good. Her company loads the card so much every year, and it rolls every year. It’s really nice. … This is like $10 just for the pills, and these are $18. It don’t come out of my pocket,” Rhoads said.
But Loretta Boesing isn’t keen on trusting the system, after more than a decade of treatment for her son’s liver transplant. “What these PBMs do is all for money. … They will just use my son's life for profit in every way they can figure out,” she said.
The family is hoping to plan a trip to Montana so Wesley can get a glimpse of Canada. He said he wants to move there one day, to escape the Missouri heat and its healthcare system. But the pilgrimage may have to wait: Wesley’s labs are showing warning signs after he went into rejection again in October.
“So … I … This is where we're stuck for now,” she said on a Saturday after her work shift. “We just tried to fill his meds and, you know, right now they're showing it's not even going to be covered. We'll have to fight for them.”
