Drug Topics Online Article – November 26, 2025 – Independent pharmacies face PBM pressures

Independent community pharmacies across the United States are facing unprecedented financial and operational pressures, many of which stem from aggressive and opaque pharmacy benefit manager (PBM) practices. As DIR fees, clawbacks, shrinking reimbursements, and vertical integration reshape the prescription drug landscape, pharmacists are being pushed to the brink — and patient care is suffering as a result.

In a powerful discussion featured in the video below, pharmacy leaders, advocates, and frontline providers describe the reality behind the headlines — and explain why meaningful reform can’t wait.

Watch the Industry Explain the Crisis

Access the original Drug Topics video HERE.

The insights shared in this video are essential for anyone who wants to understand how PBM practices threaten the future of community pharmacy — and what solutions may finally restore fairness and transparency.

PBM Practices Are Pushing Pharmacies to the Edge

For years, PBMs have imposed policies that siphon revenue away from pharmacies and distort the true cost of medications. Today, independent pharmacy owners increasingly face:

• DIR fees that appear months later and wipe out already slim margins

• Clawbacks that force pharmacies to pay money back after dispensing a prescription

• Reimbursement rates that fall below acquisition costs

• Unpredictable audits that further destabilize operations

These pressures are so intense that many pharmacists report taking emergency loans just to keep medications on their shelves. For small businesses serving underserved areas, the math simply no longer works.

The Impact of Vertical Integration

Compounding the problem is the growing vertical integration across the industry. The largest corporations now own the PBM, the insurance plan, and the pharmacy — all under the same umbrella.

This consolidation gives them the power to:

• Create exclusive pharmacy networks

• Steer patients toward corporate-owned mail order or specialty pharmacies

• Limit independent pharmacies’ ability to compete

• Prioritize drugs that yield high manufacturer rebates

• Shut out community pharmacies from fair reimbursement

Patients ultimately pay the price through reduced access, confusing communications, and abrupt medication changes that have nothing to do with clinical needs — and everything to do with corporate profit.

When Pharmacies Struggle, Communities Suffer

The ripple effects extend far beyond the pharmacy counter.
Panelists in the featured video share examples from across the country where pharmacists must choose between absorbing losses or discontinuing essential medications. In underserved communities, those decisions can mean no access at all.

Patients experience:

• Long delays in receiving medications

• Sudden out-of-network determinations

• Forced switches to higher-cost or less effective drugs

• Loss of trusted pharmacist relationships

Meanwhile, pharmacy staff must act as communicators and advocates within a system they do not control — often having to explain insurer messaging that contradicts medical advice or common sense.

Profit Over Patients: A System in Need of Reform

As formularies favor high-priced, high-rebate drugs, PBMs continue to extract value from every step of the supply chain.
This system rewards inflated list prices, encourages misaligned incentives, and undermines the fundamental purpose of healthcare: helping patients get better.

The panelists warn that without structural reform, the country will see:

• More pharmacy closures

• Fewer choices for patients

• Higher costs

• Worsening health disparities

• Declining trust in the healthcare system

The Path Forward

Reform must focus on:

• Transparent PBM practices

• Fair reimbursement tied to actual drug costs

• Protections against predatory fees

• Guardrails on vertical integration

• Policies that keep independent pharmacies open

Pharmacists, patients, and employers increasingly agree: the current model is unsustainable. The healthcare system cannot function without local pharmacies — and without action, many of them will not survive.