Since 1986, I’ve owned and operated Suburban Pharmacy in Warwick, a pharmacy my dad started in 1961. I love my work as a community pharmacist and take pride in having helped thousands of Warwick families tackle everything from the common cold to more serious chronic illnesses. My joy as a pharmacist has too often been tempered by my frustration over the predatory behavior of Pharmacy Benefit Managers. PBMs act as middlemen between health plans, pharmaceutical manufacturers and pharmacies and they have routinely forced independent pharmacy owners like me in Rhode Island to accept reimbursement rates below cost for certain prescriptions, a practice that has driven more than a dozen independent pharmacies in Rhode Island out of business over the past 20 years.

PBM practices don’t just endanger small pharmacies – they also harm the patients we’ve dedicated our careers to serving. By controlling formularies, PBMs decide which medicines are covered, often limiting options and forcing patients to switch treatments even when their doctors recommend otherwise. Add to that high copays, prior authorization hurdles and sudden coverage changes, and the result is that patients face delays, higher costs and fewer choices for the medications they rely on to stay healthy.

Seeking relief from predatory practices

My fellow independent pharmacy owners and I have been fighting for years in the Rhode Island General Assembly to get relief from these predatory PBM practices, with limited success. It’s no surprise, given the reluctance of many lawmakers to challenge one of the largest business units of CVS Health, CVS Caremark.

Thankfully, our attorney general, Peter Neronha, is not afraid to challenge CVS Caremark and other major PBMs over their unfair trade practices. On May 27, 2025, the attorney general filed a lawsuit against CVS Caremark, Express Scripts and Optum Rx. The AG‘s lawsuit references many of the allegations revealed by the Federal Trade Commission in two scathing reports on PBM abuses published last July and this January.

While CVS Caremark requires independent pharmacies like mine to accept reimbursement rates below cost, the FTC’s 2024 report highlights that CVS Caremark and the other two major PBMs mark up specialty generic drugs by hundreds of percent, sometimes exceeding 1,000%. The report also confirms my personal experience: “The Big 3 PBMs reimbursed their affiliated pharmacies at higher rates than unaffiliated pharmacies for nearly all the specialty generic drugs examined.”

In his lawsuit, the AG alleges that CVS Caremark and the other two PBMs have “unfairly and deceptively increasing the costs of prescription drugs, limiting care choices for Rhode Islanders and harming local businesses.”

Exploiting the scheme of drug pricing

The AG’s complaint goes on to allege that the “defendant Pharmacy Benefit Managers and Group Purchasing Organizations (GPOs) deceive consumers by branding themselves as a source of cost savings when in fact they profit directly from cost increases. Often secretive and unknown to consumers, PBMs and GPOs exploit the complex scheme of pricing and payment for prescription drugs, and they take a cut of ever-increasing drug prices at every step of the way. They may also make decisions about formularies – the lists of drugs that are available to plan enrollees – that unfairly restrict access to safe and effective medications.”

In Rhode Island’s ongoing battle for PBM reform, a new chapter opened recently when former CVS Health executive Helena Foulkes announced her candidacy for governor in 2026. Ms. Foulkes was a senior executive at CVS Health during the very period that the FTC alleges improper behavior by CVS Caremark.

Rhode Islanders deserve to know exactly where Ms. Foulkes stands on PBM reform and whether she supports the attorney general’s efforts to hold PBMs accountable. But this fight cannot be won in a court of law alone: Congress must also act to bring real transparency and accountability to PBMs nationwide. Thankfully, U.S. Sen. Sheldon Whitehouse helped pass a key PBM reform measure, the Modernizing and Ensuring PBM Accountability Act (MEPA), in the Senate Finance Committee, moving Congress a step closer to enacting long-overdue reform. Without federal reform, patients and independent pharmacies in Warwick and elsewhere will continue paying the price for PBM abuse.

Nick Shanos is the owner of Suburban Pharmacy.