His Inhaler Went From $66 to $539. A PBM's Drug List Is on Trial.
His inhaler went from about $66 to $539.19. He couldn't pay it.
Cole Schmidtknecht was 22, from Wisconsin, and had asthma his whole life. In January 2024 he went to refill the inhaler he'd used for more than a decade and was told it wasn't covered anymore. He left without it. Five days later, his family says, he had a severe asthma attack, and he died on Jan. 21, 2024.
His parents are suing OptumRx, the pharmacy benefit manager owned by UnitedHealth, along with the pharmacy chain where he tried to fill it. I'm a pharmacist, and I think every patient should understand what this case is about.
What the Lawsuit Says Happened
These are the allegations in the family's federal complaint, filed in January 2025 in the Eastern District of Wisconsin.
Cole managed his asthma with daily doses of Advair Diskus and its generic equivalents. He got health coverage through his job, on a self-insured plan administered by UnitedHealth, with OptumRx as the PBM. Under that plan in 2023, the complaint says, his inhaler cost no more than about $66.86, even in the deductible phase, and about $35 after that.
What the complaint says he paid | |
2023, deductible phase | About $66.86 |
2023, after the deductible | About $35 |
January 2024, at the counter | $539.19 |
The complaint alleges OptumRx removed Advair Diskus and its generics from its formulary for 2024 and never gave him the 30 days' notice Wisconsin law requires. Without that notice, the family says, he had no chance to ask for an exception before he was standing at the register.
A Formulary Is a Contract You Never See
A formulary is the list of drugs a plan covers. The PBM builds it, and it changes. Drugs move between tiers, get excluded, or get replaced with something the PBM prefers.
The family's complaint alleges OptumRx dropped Cole's inhaler not for a medical reason, but because makers of competing drugs gave OptumRx financial incentives. That's the core of the case.
The complaint quotes the message OptumRx's system sent back on Cole's claim: "Premium Drug Exclusion: Drug Not Covered; Contact prescriber." That's what a formulary change looks like from the inside. A code on a screen, and a patient standing at the counter waiting to hear what it means.
You never sign that list. You usually never see it until something on it changes. And the change can turn a $66 refill into a $539 one with nothing different about your diagnosis or your prescription.
What OptumRx and the Pharmacy Say
According to the complaint, OptumRx said in a statement that the pharmacist should have contacted Cole's doctor about three covered alternatives at a lower tier: Advair HFA, Breo Ellipta and Symbicort. The complaint says nobody at the pharmacy offered those options or contacted his prescriber.
The pharmacy chain, in its court response, denied wrongdoing and said it acted reasonably and in good faith, according to the Green Bay Press-Gazette. It also said Cole's visit was on Jan. 12, not Jan. 10.
A Judge Let the Case Go Forward
OptumRx asked the court to dismiss the case, arguing that ERISA, the federal law governing employer benefit plans, blocks claims like this one.
In July 2025, U.S. District Judge Byron Conway denied that motion. He wrote that "a claim that a PBM was negligent because it failed to provide a beneficiary with notice that his prescription would no longer be covered, and thus his out-of-pocket cost would greatly increase, does not implicate any of the policies underlying preemption." He also noted ERISA could still apply depending on the facts.
The ruling describes the end of Cole's life plainly. He became unresponsive on the way to the hospital, and after six days on a ventilator in intensive care, doctors told his parents nothing more could be done. The case is still moving through federal court.
Why This Keeps Happening
Formulary changes happen every year, usually on Jan. 1. Patients are supposed to be warned. In practice, plenty of people find out the way Cole did, at the counter, holding a price they weren't expecting.
When the company writing the drug list is also collecting money from drugmakers, the list can reflect those deals as much as it reflects what's best for you. That's one more way the middleman decides what you pay.
No Formulary Here
Forest Park Pharmacy doesn't take insurance and has no PBM contracts. There's no drug list deciding what's covered, because nothing is "covered." Every drug is priced at actual acquisition cost plus a transparent fee, and you can look up the price on our website before you ever transfer a prescription.
That also means nobody on our end gets paid to prefer one drug over another. If your doctor prescribes it and we carry it, the price is the price. It doesn't change on Jan. 1 because a contract changed, and you don't find out what it costs at the register. You find out on our price checker, before you decide anything.
We have no reason to pretend the price is higher than it is. We compete on price.
Head to forestparkpharmacy.com to look at our price checker and transfer today to save. See ya.
