For the past five years, Alpena resident Selena Kenny has received a bulk supply of medication every three months from Express Scripts.
Her Medicare Advantage plan labels mail-in services as its preferred pharmacy because it offers the lowest price for her blood pressure and cholesterol medication.
“For most of the medications that I take on an ongoing regular basis, it's very convenient to have them come through the mail,” Kenny said.
Mail-in prescription services from pharmacy benefit managers like CVS Caremark, Express Scripts and Optum Rx have been an answer for patients in rural areas that lack quick access to a pharmacy.
Independent pharmacies also rely on pharmacy benefit managers to negotiate drug prices and handle prescription reimbursements.
Over the years, these managers and their parent companies have gained control of several aspects of the nation’s health care system, such as online pharmacies and connections to various insurance companies.
State officials and independent pharmacists are now saying these companies are helping cause pharmacy closures. According to the Michigan Pharmacists Association, 272 pharmacies closed their doors in 2024, 91 of them being independent pharmacies.
Many of those closures were part of the chain pharmacy Rite Aid’s withdrawal from Michigan after filing for bankruptcy two years in a row.
Pharmacists fear that if more brick-and-mortar pharmacies close, patients will lose out on services that mail-in orders can’t provide — such as vaccinations, timely antibiotic refills and basic clinical care.
“What we're seeing is a reduction in the quality of care for Michiganders when an independent pharmacy closes, and the patients in that community only have the ability to use mail order as an alternative,” said Eric Roath, the director of government affairs for the Michigan Pharmacists Association.
Ashley McGinn is a counselor for Michigan’s State Health Insurance Assistance Program. She said some patients won't leave their local pharmacy for a “$100 difference.”
But as drug prices remain costly, people continue to switch to more online services.
“Last year, I helped a little over 100 people, and I'd say probably 80% are going with the mail order,” McGinn said.
She said it's because insurance companies often prefer them.
“Insurance plans are going toward mail order as their preferred pharmacy, which in turn gives you a cheaper prescription,” said McGinn. “In Presque Isle County, a lot of our older residents have transportation issues, so that eliminates their transportation problem, but our local smaller pharmacies are seeing a hit in that.”
Major retailers like Walmart and Amazon have also started speedy mail-in prescription services, following a trend of online medical services that have grown since the COVID-19 pandemic.
According to pharmacists, it's also a struggle to keep up with the costs of maintaining a brick-and-mortar store because of the reimbursement rates set by the managers.
Losing business to mail-in orders’ competitive co-pay pricing is not helping.
“Not only is there not money to pay for the cost of the pharmacist, the techs, the lights, the insurance and everything that goes into filling a prescription ... there's not even a payment that's covering the cost of the drug that we're purchasing to give to the patient,” said John Gross, an independent pharmacist who owns six stores across central Michigan.
He said that the rates can make turning a profit a challenge for pharmacists.
“You don't make a pizza for $5 and sell it for $4 if you're a pizza place, because you've got overhead that's involved with that,” Gross said. “It's the same thing with a pharmacy.”
In July 2024, the Federal Trade Commission reported that CVS Caremark, Express Scripts and Optum Rx managed around 80% of all prescriptions filled in the United States.
The commission stated that because these managers control over the drug industry’s supply chain, they can “exercise significant power over Americans’ access to drugs and the prices they pay.”
They released another interim report in 2025, saying the companies “marked up numerous specialty generic drugs dispensed at their affiliated pharmacies by thousands of percent, and many others by hundreds of percent.”
Pharmacy benefit managers dispute role in pharmacy closures
“We save Michigan’s business community and its employees money while strengthening health outcomes with the help of our coordinated model, which recognizes the important role that independent pharmacies have today,” wrote an Express Scripts spokesperson in an email to Bridge Michigan.
“That’s why employers, government entities, and other health plan sponsors across the state choose to work with us, because our coordinated model provides them the ability to choose a network that can incorporate large chain, regional and independent pharmacies, in addition to home delivery, so that the unique and evolving needs of their business and their employees are met.”
Pharmacy benefit managers continuously deny that they are the cause of pharmacy closures across the country. The Pharmaceutical Care Management Association, a national organization that represents managers, claims that the independent pharmacy industry is stable.
They reported that independent pharmacies have increased from 1,086 to 1,091 (0.5%) across the state since 2022.
“Optum Rx gives people several ways to get their medications, including through community and independent pharmacies, retail pharmacies, specialty pharmacies and home delivery,” said Katherine Wojtecki, a spokesperson for Optum Rx. “Together, these options help make medications more accessible and convenient for the people we serve.”
As pharmacists continue to advocate against pharmacy benefit managers, state and federal officials have begun to take action against these companies.
Michigan Attorney General Dana Nessel filed a lawsuit in 2025 alleging that Prime Therapeutics LLC, a pharmacy benefit manager affiliated with Blue Cross Blue Shield, adopted “Express Scripts’ lower reimbursement rates in exchange for accessing Express Scripts’ buying power and pharmacy network” and that these practices are hurting small pharmacies.
Prime Therapeutics LLC stated that the agreement has helped patients save money.
“The arrangement in question has delivered billions of dollars in savings, while lowering costs at the pharmacy counter and helping ensure tens of millions of Americans get the medications they need,” wrote Jim Cohn, a spokesperson for the manager, in an email to Bridge Michigan. “We are committed to fair and sustainable reimbursement for pharmacies, and will continue to support solutions that promote more transparent, predictable pharmacy pricing while protecting affordability and access for the people we serve.”
President Donald Trump signed legislation toughening regulation of PBMs into law as part of February’s spending bill in an effort to lower drug prices.
However, many of the changes, such as changing how PBMs are paid by drugmakers, won’t take effect until 2028.
“The thing that has happened kind of over the past 10 years or so is that (pharmacy benefit managers) have figured out sort of loopholes in business/health care policy in the US that have allowed them to become much more profitable,” said Joe Fava, a pharmacy practice professor at Wayne State University.
