Katherine Montgomery lives in Sacramento. For over two decades, she’s worked for the State of California. She also lives with severe diabetes. Right now, she’s gravely concerned for her health: Her dangerously high blood sugar is responsive to only a single medication, and for weeks — despite traveling to a dozen individual Walgreens locations — filling her prescription has been a total impossibility. At each store, the Walgreens pharmacists have sent her away empty-handed, citing shortages of the drug she needs.

Then she decided to try Pucci’s, a small independent pharmacy chain with locations in Sacramento and Los Angeles. Clint Hopkins, the owner of Pucci’s, was able to explain to her why pharmacies weren’t able to fill her prescription.

As for Walgreens’s insistence that shortages are hampering Montgomery’s access to medicine, as Hopkins later related to Truthout by phone, “That is actually a lie. It’s plentifully available. [Pucci’s] uses the exact same distributor. There is no reason they should not be able to get it. They’re just choosing not to, because they also know they’re losing money if they’re filling it. Whether it’s at the store level they know, or the district level, or it’s Walgreens corporate, somebody is blocking the purchase of that drug.”

Montgomery’s situation is only one of many across California, and the nation writ large, in which an individual’s health is in jeopardy as a result of the machinations of a little-known species of health care corporation: pharmacy benefit managers (PBMs).

Ostensibly, as their lobbyists contend, the role of PBMs is to bargain with drug manufacturers for discounts and rebates, then furnish the drugs to insurance plans and pharmacies while passing on the negotiated savings — and taking a cut for themselves. PBMs also determine an insurance plan’s “formulary,” i.e. the medications made available to people on a certain plan. The reality is that PBMs, far from mitigating drug costs, leverage their middleman position to dictate the price and availability of prescription medicines, extracting fees and engineering transactions to their advantage. At the end of the chain, adverse financial and health effects are inflicted on everyday people.

Hopkins went on to describe how PBMs, out of self-interest, will deny or make unaffordable any medications that are unprofitable for them, or just not profitable enough — even if patients’ lives are in the balance. By dictating impossible terms, PBM pressures render pharmacies, independents and chains alike, unable to fill certain prescriptions without taking a considerable loss. For this reason, Montgomery was also unable to update her medication through Pucci’s.

Hopkins, as a small pharmacy owner, is put in an impossible bind: Independent pharmacies can’t survive losing hundreds of dollars each time a prescription is filled. Many pharmacies will refuse to sell certain drugs, while claiming ignorance or furnishing excuses to patients. Hopkins says he tries to be up front about the situation, though it’s not easy.

“Having to have that conversation with patients — they’re just blindsided,” said Hopkins. “Like, ‘I can’t believe that I’m paying a thousand dollars a month for health insurance’.… It just doesn’t make sense to them. People don’t understand it — but they shouldn’t have to! You should be able to use whatever pharmacy you want!”

Weeks of elevated blood sugar put Montgomery in real danger of diabetic coma, stroke or other fatal consequences. Each day of additional delay amplified the terrifying risk. Speaking with Truthout, Montgomery reflected on the difficulties she faced. “My blood sugar is off the charts.… I can’t even express how angry it makes me. I’m flabbergasted. I know that it’s profit over people … but they just keep coming with new ways to do it, and new ways that are just so egregious. You think, ‘How could they possibly get away with this?’ But, they probably will!”

California has long been notable for its comparatively lax regulatory stance towards PBMs — a gap that state lawmakers had planned to address when, in late August, they passed Senate Bill 966. The bill was coauthored by Democratic State Senators Scott Wiener and Aisha Wahab and backed by a coalition of professional associations and patient rights advocates, including the California Pharmacists Association, the National Community Pharmacists Association and Unite for Safe Medications. SB 966 would have instituted the first medical licensing requirements on PBM operations in the state and bolstered transparency and accountability measures. Passed in the State Senate with resounding bipartisan assent, it then went to the desk of Gov. Gavin Newsom — who, just as advocates had feared, vetoed it.

SB 966 would have instituted the first medical licensing requirements on PBM operations in the state and bolstered transparency and accountability measures.

The Office of the Governor released a statement on the veto, in which Newsom said, “Without a doubt, the public and the Legislature need a clearer understanding of how much PBM practices are driving up........

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