Americans are facing skyrocketing prescription drug costs, and while drug companies and insurers are often blamed, pharmacy benefit managers (P.B.M.s) play a significant role in driving up prices. These powerful middlemen oversee prescriptions for over 200 million Americans, working on behalf of large conglomerates like CVS Health and UnitedHealth Group. Despite their primary job being to reduce drug costs, P.B.M.s frequently do the opposite by steering patients towards more expensive medications, charging high markups on cheaper drugs, and collecting billions in hidden fees. This opacity and complexity in the healthcare system allow P.B.M.s to operate largely unnoticed, contributing to the overall cost of healthcare for individuals, employers, and the government. As Americans bear the burden of high prescription drug prices, it is clear that addressing the practices of pharmacy benefit managers is crucial in tackling this issue.