[lotsofpulp]

PBMs are just departments in managed care organizations (MCOs), aka health insurance companies nowadays. MCO profit margins are 5% or less, so if you buy coverage from an MCO, it makes no difference to you what the PBM division does. Any money made by PBM divisions just goes to offset expenses in the insurance division. If the PBM makes less money, then insurance premiums have to go up.

The chain of money goes from managed care/insurance buyer (individual/employer/government) to MCO to healthcare provider, whether it be a pharmacy, a drug manufacturer, a hospital, or a doctor. The fact that the middle has a tiny profit margin means there is not much juice to squeeze there.