PBMs hold an incredible amount of power. The Acquired podcast did a marvelous breakdown of the American pharmaceutical industry while covering Novo Nordisk (https://www.acquired.fm/episodes/novo-nordisk-ozempic). If you have three hours to spare, I highly recommend giving it a listen.
The health insurers (or more accurately, managed care organizations) are loving the blame that the PBMs get.
It makes the issue just a little more complicated, and thus turns people off from reading into it.
There is no need to refer to health insurers and PBMs separately, they are one and the same with the same bosses for the vast majority of people.
So the complaint really boils down to health insurers not paying enough for medicine.
However, given that health insurer’s profit margins are low single digits, what is actually happening is they are squeezing their vendors wherever they can, however they can, and using these opaque rules is one way to do it. Not really any different than Geico paying Safelite, but due to myriad laws and different insurance plans, the complexity can be greatly increased in healthcare.
Also, Cuban is all talk, no walk. He just wants to try to be another middleman. The real innovation would be building medicine factories and selling medicine for cheaper, but no one really wants to do that since it is high risk low reward.
Another great interview comes from Mark Cuban, who is serious about disrupting PBMs with his Cost Plus Drug Company (https://www.drugchannels.net/2024/03/mark-cuban-five-ways-th...).