PBMs skim a slice of drug manufacturer rebates instead of passing all savings to the plan.

In 2024, the total rebate, discounts, and other price concession for brand-name drugs was estimated to be $356 billion.

In employer-sponsored & individual plans, rebates are 20-22% of gross drug spending.

It’s more than the GDP of Finland ($314B) and nearly the size of Denmark ($407B).

PBMs pay pharmacies one price, bill employers more, and keep the difference.

Example: pay pharmacy $80, bill plan $100 → pocket $20 per prescription.

Multiply that margin across millions of claims, and the “spread” becomes a hidden tax on employers.

It is estimated based on U.S. prescriotin drug spending and what’s known about spread margins, PBMs easily be pocketing tens of billions.

PBMs give “preferred” status to drugs that deliver the fattest rebates, even if cheaper or more effective options exist.

Employers pay more, patients get stuck with higher copays, and the PBM still boasts about “savings.”

Coupons are dangled to ease the patient’s copay pain — but the employer still gets stuck with the giant bill.

PBMs push patients to their own rebadged or “preferred” biosimilars.

It’s often just the expensive brand in disguise, dressed up so employers think they’re getting savings.

Of course, these “biosimilars” come with rebates too — which PBMs pocket — so the shell game keeps rolling.

PBMs don’t just run the benefit — they own the mail order, the specialty pharmacy, and sometimes even the clinics.

By controlling the entire supply chain, they set the rules, steer patients, and stack markups at every step — feeding their own pockets the whole way through.

PBMs bury charges in contracts under labels like “administrative,” “inflation,” or “data” fees.

These extras drain employer budgets quietly, often without any visibility.

PBMs monetize claims data by selling, aggregating, or repackaging it as “consulting services.”

Translation: they sell your own data back to you.

At the same time, they make employers feel like they can’t even look at their own claims data — keeping the numbers opaque so the tricks stay buried.

From copay accumulators and clawbacks to rebate walls, vague definitions that let them dodge “100% rebate pass-through” promises, and data monetization schemes, PBMs have built a playbook of hidden fees and fine-print tricks to keep costs high and profits higher.

Really, there are more ways, but isn’t this enough?