Amye Joseph observes that the nation’s political divide has turned life at her Tennessee home into an “interesting time.” She and her spouse, Charlie, have shared 35 years of marriage. She identifies as a Republican; he aligns with the Democratic Party. Their frustration with a profit-driven health system has pointed them toward pharmacy benefit managers, or PBMs. The Josephs direct their discontent at CVS Health, a conglomerate that posted $400 billion in revenue last year and owns health insurer Aetna, PBM CVS Caremark and nation’s biggest retail pharmacy chain.
Amye Joseph expressed her dissatisfaction with CVS, stating that she dislikes the company. She criticized the lack of personal interaction with pharmacists, unexplained price increases, and the pressure to use CVS stores from her CVS Caremark drug plan. Joseph described CVS as a ‘money grab’, emphasizing that they are not a necessary intermediary. ‘They’re not even a middleman,’ she said. ‘They’re a money grab for CVS.’
PBMs Under Fire
The original purpose of pharmacy benefit managers, or PBMs, was to manage prescriptions and reduce costs. However, these intermediaries have become a target for criticism from both parties, accused of profiting at the expense of employers, governments, and patients. Despite ongoing debates over healthcare in Washington, D.C., taking on PBMs has become a unifying issue amid widespread frustration over rising healthcare costs.
In recent years, every state has imposed restrictions on PBMs. Tennessee, where the GOP has a lock on state government, is among a growing number looking to outlaw companies that own PBMs from also owning brick-and-mortar pharmacies, as CVS does. This move has brought together conservative Republicans and Democrats who traditionally support government regulation.
Legislative Push and Industry Opposition
This legislative push reflects a feeling even in the GOP that the market for prescription drugs is being gamed, said Antonio Ciaccia, CEO of 46brooklyn Research, a nonprofit think tank that tracks drug pricing. “Republicans are looking at this issue, saying, We know what competition is supposed to do, and it isn’t happening,” Ciaccia said. “This is not a free market.”
Charlie Joseph, a retired fire captain who now works as a custodian, was miffed when he realized he could save money on his blood pressure medication if he paid cash at his local pharmacy rather than using his CVS Caremark drug plan. He now buys a 90-day supply for the same price he would have paid for a 30-day supply through the CVS plan. “Right now, it’s more of an inconvenience than anything else as far as it goes, but there’s no consistency,” he said. “The whole healthcare thing is just frustrating, on a good day.”
CVS and the Industry Respond
CVS spokesperson Phil Blando said the price of individual drugs can vary. “Looking at the price of a single prescription does not reflect the value of a full pharmacy benefit,” he said in a statement. “Our focus remains delivering the lowest possible total cost and the greatest overall value for members and plan sponsors.” PBM officials say their industry has been unfairly maligned. “PBMs are the only part of the prescription drug supply chain working to lower drug costs, which makes PBMs the target of powerful groups, Big Pharma and pharmacists,” said Greg Lopes, a spokesperson for the Pharmaceutical Care Management Association, which represents PBMs across the nation. “Drug manufacturers attempt to shift blame for high drug costs to PBMs in order to retain their profit margins and weaken PBMs’ ability to lower costs,” he said.
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Drugmakers have worked for years to cast PBMs as unnecessary go-betweens, said Barak Richman, a lawyer and economist who studies healthcare competition at George Washington University. He called the fight between the two industries a corporate “cage match.” “We have wildly passionate partisan divides on a lot of healthcare,” he said. “But there’s a lot of healthcare policy that I don’t think is obviously partisan.”
State Laws Tackle PBM Practices
Attorneys general from nearly 40 states and U.S. territories wrote a letter last year to congressional leaders arguing that “horizontal consolidation and vertical integration have transformed PBMs from useful administrative service providers into market-dominating behemoths.” In state legislatures like Tennessee’s, shared ownership of PBMs and pharmacies has drawn particular fire. Independent pharmacies have little choice but to contract with major PBMs while also competing with the conglomerate-owned pharmacies. Many lawmakers have said they want to protect small businesses.
“If a corporation argues that its pharmacy cannot survive unless it is owned by the same entity that sets the reimbursement rate, then we’re not talking about a free market. We’re talking about control,” Tennessee state Sen. Bobby Harshbarger said. Harshbarger, a Republican who led the legislative push, is a pharmacist in a small city in northeast Tennessee.
The Tennessee Vote and Its Aftermath
CVS officials argued the Tennessee legislation was misguided. “Any proposed reform should be evaluated based on whether it improves access to care, simplifies the patient experience, and enhances affordability,” Blando said. It’s unclear whether the PBM ownership ban will do that in Tennessee. An analysis by the state legislature’s researchers concluded that the bill could drive up healthcare costs in the short term. To fight the bill, CVS launched a $7 million TV advertising campaign, claiming it would have to close all its 134 pharmacies in the state, similar to its threat in neighboring Arkansas when state lawmakers there passed a similar measure in 2025.
CVS also sent text messages to Tennessee customers, asking them to contact their lawmakers to keep pharmacies open. Ominous texts from CVS helped kill a PBM ownership ban in Louisiana last year. Sponsors of the legislation said closure wasn’t the only option: CVS could also divest either its stores or its PBM. Tennessee lawmakers moved forward. State Sen.
Rusty Crowe, a Republican from northeast Tennessee, where the Josephs live, told his colleagues before the vote that they should consider the fierce resistance a sign that they were onto something. “I learned when I was in the Vietnam War, when you start taking on flak, you know you’re over the damn target,” he said. As with most votes in Tennessee’s legislature, Republicans didn’t need support from Democrats. But they got it anyway. State Rep. Antonio Parkinson, a Democrat from Memphis, said he felt like he was voting in favor of lower drug prices and supporting “ma and pa” pharmacies. “If there’s a benefit to my people, I’m supporting it.”
