CVS net profit margin is in the 2% to 3% range:

https://www.macrotrends.net/stocks/charts/CVS/cvs-health/pro...

Cigna purchased Express Scripts in Mar 2018, and has profit margins of 3% to 5% over the last couple years.

https://www.macrotrends.net/stocks/charts/CI/cigna/profit-ma...

If these PBMs are making lots of profits, then they are simply subsidizing losses elsewhere in the MCO. The total costs paid for insurance premium plus out of pocket costs by the end user in the US would not be affected.

You are not addressing my main point which is that these MCO's distort their "net margin" stat using accounting tricks. And yes PBM's are INCREDIBLY profitable. Express scripts made 4.5 billion in net income in 2017. They have never produced a drug that has saved a life.

PBMs are important but they should not be able to put a gun to these pharma companies heads because they control the formulary.

CVS net margin includes their retail business. You can't compare AWS's margin to Walmart's e-commerce margin.

I am not addressing it, because I do not see any further evidence of distortion of an MCO's net profit margin other than what this article claims. Nor would it matter to me unless some MCO executives are smuggling cash out of the country or something.

As a customer, it does not affect me.

In the healthcare business, the flow of money is:

Individual -> MCO (insurance company) -> healthcare providers and drug manufacturers

What does it matter to the individual what portion of an MCO is earning what profit if the net profit margin of the whole MCO is 5% or less? They are obviously not left with a lot of money, their employees are not known to be lavishly compensated.