Cole Schmidtknecht died over $67

When 22-year-old Cole Schmidtknecht walked into his local Walgreens on January 10, 2024, he expected to pay $66.86 for a three-month supply of his preventative asthma inhalers in January 2024 when he went to his Walgreens pharmacy in Appleton, Wisconsin.

The drug store told him it would cost $539.19, because his insurance company made changes without telling him. 

Unable to afford the cost, he left empty-handed. Five days later, he suffered a fatal asthma attack. His death, now at the center of a wrongful-death lawsuit, has ignited scrutiny of America’s fractured healthcare system and the opaque practices of pharmacy benefit managers (PBMs) that critics say prioritize profits over patients.

Cole, a parts sales employee at a trucking company, had battled severe asthma since infancy. His parents, Bil and Shanon Schmidtknecht, both lifelong asthmatics, watched him grow into an active teenager who played football and rarely needed emergency care—thanks to Advair, a corticosteroid inhaler he used daily. “It was pretty life-changing,” Shanon recalled. “He was just a normal, active kid.”

For years, Cole paid a $67 co−pay every three months under his employer−sponsored insurance plan managed by OptumRx, a PBM subsidiary of United Health Group.

But on January 10, Walgreens staff allegedly told him Optum had abruptly dropped coverage for Advair, leaving him responsible for the full $539 cost—a price tag far beyond his hourly wage.

Without his preventative medication, Cole relied on an emergency albuterol inhaler until he collapsed during a catastrophic asthma attack on January 15.

By the time his roommate rushed him to ThedaCare Regional Medical Center, Cole had no pulse. He was declared brain-dead days later and removed from life support on January 21.

In a 26-page federal lawsuit filed in Wisconsin’s Eastern District, Cole’s parents accuse Optum Rx and Walgreens of negligence and wrongful death. Their attorney, Michael Trunk, claims Optum violated Wisconsin law by failing to notify Cole or his doctor of Advair’s removal from its formulary, denying him time to seek alternatives.

Walgreens, meanwhile, allegedly neglected its duty under the 1990 Omnibus Budget Reconciliation Act to counsel patients on affordable medication options.

“It was so preventable,” Shanon said, her voice breaking. “We want justice for our son and to ensure this never happens to another family.”

Optum Rx declined to comment but previously told local media it had instructed Walgreens to direct Cole to three covered alternatives. Walgreens also declined to comment. Legal experts, however, note the case hinges on whether the pharmacy fulfilled its obligation to inform Cole of substitutes. Barry Furrow, a health law professor at Drexel University, called the failure to advise “the strongest part of the lawsuit” but warned Walgreens may argue Cole should have proactively sought alternatives.

The lawsuit spotlights PBMs—middlemen like Optum Rx that negotiate drug prices for insurers—and their controversial role in driving up costs.

Cole’s parents allege PBMs accept “kickbacks” (framed as rebates) from drugmakers to favor expensive brand-name drugs over generics. Advair, for example, earned manufacturer GlaxoSmithKline (GSK) over $68 billion between 2000 and 2021, despite its patent expiring in 2008.

“It’s so opaque. It’s guesswork what’s happening behind the scenes,” said Dr. William Feldman, a Harvard pulmonologist who testified before Congress in 2023 about GSK’s tactics to delay generic competition. While three Advair generics exist, PBMs often exclude them from formularies if brand-name rebates dry up. For patients like Cole, sudden coverage changes can be deadly.

Bil Schmidtknecht has channeled his grief into activism. Weeks after Cole’s death, he quit his job and joined a small PBM to advocate for industry reform. He’s now lobbying Wisconsin lawmakers and federal agencies to ban PBMs from underpaying pharmacies and accepting rebates that inflate drug prices. “That’s got to stop,” Bil said. “I have his voice, and I’m doing this for everybody.”

His efforts align with growing bipartisan scrutiny of PBMs. The Federal Trade Commission is investigating their role in rising drug costs, while Congress mulls bills to increase transparency.

Cole’s story underscores how systemic flaws—from PBM practices to lax patient protections—can cascade into tragedy. Dr. Feldman noted that even if alternatives exist, “so many things need to go right” for patients to access them. “There are so many cracks in the system,” he said.

For the Schmidtknechts, those cracks stole a son who loved football, his younger brother Dane, and life itself. As Bil whispered goodbye, his head resting on Cole’s chest, he vowed to fight for a world where no family endures such loss. “We’re going to push until something meaningful is done,” he said. “People should never die because they can’t afford to breathe.”