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Losing the Reimbursement Battle? Win the War with a Smarter Pharmacy Purchasing Strategy
“A missed opportunity,” is how the American Pharmacists Association (APhA) described the failure by the U.S. Congress to enact pharmacy benefit manager (PBM) reform before adjourning in December 2024. Similarly, the National Community Pharmacists Association (NCPA) called the failure “a clear miss by Congress,” and noted the issue has broad bi-partisan support and “may be the only issue in Washington that [all sides] agree on.”
Independent Pharmacies Face Unrelenting Reimbursement Challenges
Reining in PBM practices has long been a top priority for the nation’s independent pharmacies. In the waning days of the 118th Congress, it seemed that victory was finally at hand. That’s because, as legislators put together a spending package to continue funding the federal government into 2025, hoped-for PBM-related provisions were added, sparking cautious optimism throughout the pharmacy community. But just as quickly as they were added, the provisions were stripped out of the final version. Congress passed the revised spending plan, leaving pharmacists disappointed and disheartened.
As pharmacy advocates continue the battle for meaningful reform, community pharmacists face yet another year of egregious PBM practices including, of course, decreasing reimbursement rates. Pharmacies are not adequately reimbursed for the costs of medications provided to patients. For many pharmacies, this has had an existential effect, with NCPA reporting that independent pharmacies were closing at a rate of roughly one per day.
Florida pharmacist Kevin Duane provided a compelling assessment of current reimbursement practices when, in testimony before the U.S. House Committee on Oversight and Accountability he explained: “I have always considered small business ownership to be ‘an American dream,’ but the experience in my field could better be described as a nightmare, and the monster in that nightmare is a PBM.”
Duane explained that PBMs present pharmacies with “take-it-or-leave-it” contracts “where the reimbursement rates are significantly below our costs to purchase brand drugs.” Under-reimbursements affect all types of medications, he explained: “Some of the most basic yet most life-sustaining medications – drugs to prevent heart attacks, blood clots, or transplant rejections, for example – are commonly underpaid compared to the true market cost.”
Eliquis and Beyond: Shocking Examples of
Under-Reimbursement
Sentiments like this are widespread throughout the pharmacy community. Consider for example:
- Research by the New York Times found that with regard to the blood thinner Eliquis, pharmacists located in different states reported reimbursements as much as $100 less than what it cost them to purchase the medication from a wholesaler.
- A survey by NCPA found more than 90% of independent pharmacies may opt out of stocking the 10 drugs for which Medicare Part D recently negotiated lower prices. According to NCPA, pharmacists would have to front as much as $27,000 of their own money each month to stock the drugs, and then wait several weeks for a likely “underwater reimbursement.” The drug price changes are scheduled to take effect in January 2026.
- Research by the Oregon State Pharmacy Association determined that roughly 75% of claims examined “were insufficient to cover the pharmacy labor and drug costs.”
- Research by the New York City Pharmacists Society found almost 90% of local independent pharmacies said they had “been forced to turn away patients” due to sub-par reimbursement rates.
- More than half of pharmacy owners are losing money on over 60% of the Part D prescriptions they fill, according to NCPA.
While the situation certainly seems grim, there is reason for hope. For one thing, pharmacies can fight back by ensuring they don’t pay a penny more for the medications they stock than is necessary. This is possible through the PrimeRx MARKET online marketplace, which provides pharmacies with real-time access to the most competitive prices on brand and generic drugs from a wide range of suppliers.
PrimeRx MARKET: A Solution for Smarter Pharmacy Purchasing
With PrimeRx MARKET, pharmacies can be confident they are accessing highly competitive prices for each drug. They no longer have to spend hours jumping from one website to another, conducting cost comparisons. Key capabilities and benefits include:
Direct access to more than 40 drug wholesalers and suppliers.
Pharmacists can easily compare prices, identify best sources for different types of drugs, and seamlessly submit orders with multiple providers.
Single-source solution for all medication/inventory needs.
Pharmacies can shop for a wide range of medicines including brand-name drugs, generics, and over-the-counter products, among other offerings.
Fast, accurate results.
Pharmacists no longer have to spend time checking with multiple suppliers to identify the best pricing for a specific drug. Instead, PrimeRx MARKET generates a comprehensive side-by-side comparison of each supplier’s pricing for a requested drug. The system generates immediate results in a user-friendly format.
Immediate, transparent savings.
Pharmacies can purchase the medications they need at the best available price upfront, eliminating the need to rely on delayed rebates to reduce costs.
PrimeRx MARKET is offered by PrimeRx, a leading provider of software solutions designed specifically for the independent pharmacy market. PrimeRx pharmacy management systems can be found in thousands of pharmacies nationwide, helping pharmacists meet the demands of their busy workloads. PrimeRx MARKET is a natural complement to the PrimeRx brand, and another solution that addresses a community pharmacy need.
Empowering Pharmacies with PrimeRx MARKET While Advocacy Persists
Hopefully 2025 will be the year when pharmacy benefit managers are finally held to account for the tremendous harm they have caused. In a January 2025 Chain Drug Review opinion article, NCPA CEO B. Douglas Hoey stated that “changing the pharmacy payment model” would be the group’s top priority going forward. He vowed to seek reform through state and federal legislation, by promoting regulatory changes, and through the courts. While he was careful not to overpromise, Hoey noted that the fight against PBMs “is a fight we’re pursuing relentlessly.”
In the meantime, pharmacies can take control of their drug costs by leveraging PrimeRx MARKET to secure significant savings on medications.
Your Pharmacy Marketplace: PrimeRx MARKET
