Rob Sand, Iowa State Auditor and candidate for Governor, said on May 18 that pharmacy benefit managers (PBMs) have too much control over prescription drug costs and how Iowans access medication, and said that, as governor, he would work to restructure the PBM system to improve affordability and access.
“Middlemen like PBMs (Pharmacy Benefit Managers) have undue influence on prescription costs & how Iowans access medication. That's wrong. As governor, I'll break up PBMs and make sure Iowans get a fair deal on their medicine,” Sand said on social media.
The role of pharmacy benefit managers (PBMs) in the prescription drug market has become a central issue in Iowa’s debate over medication access and affordability. Sand’s comments come amid ongoing concerns about the influence of these intermediaries on drug pricing and local pharmacy viability.
Iowa enacted SF 383 in 2025 to regulate pharmacy benefit managers, pharmacies, prescription drugs, and pharmacy services administrative organizations. The law took effect July 1, 2025, after being signed by the governor on June 11, 2025, placing PBM oversight at the center of Iowa’s prescription-drug access and pharmacy-reimbursement debate, according to the Iowa Legislature.
The pharmacy benefit manager market is highly concentrated, with the six largest PBMs managing nearly 90% of prescriptions filled in the United States.
The three largest PBMs are affiliated with health insurers, giving vertically integrated firms significant influence over drug pricing, pharmacy networks, formularies, and patient access to medications, according to the Federal Trade Commission. In Iowa, 29 pharmacies closed in 2024, and 204 closed statewide between 2014 and 2024, according to the Iowa Pharmacy Association.
Sand is Iowa’s 33rd State Auditor, first elected in 2018 and taking office in January 2019. A Democrat, he is a candidate for governor of Iowa in 2026. As state auditor, he is responsible for overseeing government spending, conducting financial and performance audits of state and local entities, and helping ensure accountability and transparency in public funds.
