PMOs were supposed to give small pharmacies leverage. Now they’re just another layer in the stack. Most of the big ones are owned by wholesalers anyway, so “choice” usually means picking which middleman you like. Three wholesalers and three PBMs control almost everything. The PMOs just make it look plural. Joining a PMO is survival math. Opting out isn’t brave—it’s financial suicide. It’s not a legal monopoly. It’s a network you can’t afford to leave. Independents didn’t get crushed—they got slowly absorbed under “management services.” “Independent pharmacy” is now more of a tax status than an actual business model