ACCESS to Pharmacy Care Model Lets Pharmacists Bill for Chronic Care

Under a new model spearheaded by the Centers for Medicare & Medicaid Services (CMS), with support from the National Community Pharmacists Association (NCPA), independent pharmacies can now be paid for managing patients with chronic conditions through the ACCESS to Pharmacy Care Program.

“We’re at a point where pharmacies have been closing more rapidly than we would like to see,” Mark Ey, RPh, senior vice president and chief operating officer with NCPA, told Drug Topics®. “This gives pharmacists an opportunity to engage in care services that, in the past, they’ve not been reimbursed for.”

Historically, pharmacy reimbursement has focused on commodity dispensing rather than clinical outcomes. The ACCESS to Pharmacy Care Program, finalized in September 2026 following initial releases in late 2025, represents a dramatic pivot toward value-based performance. Under this 10-year national initiative managed by the CMS Innovation Center, participating community pharmacies can receive payments of up to $100 per patient per clinical track annually.¹

Current tracks include diabetes, prediabetes, hypertension, behavioral health, and musculoskeletal conditions, with expansion planned for April 2026 to cover heart failure, chronic obstructive pulmonary disease (COPD), substance use disorder, and smoking cessation. Because many Medicare patients present with multiple chronic conditions, pharmacies could generate $200 to $300 per patient each year through quarterly, 5-minute monitoring calls.²

READ MORE: PBM Underpayment Persists as Cost-Plus Brings New Strain | NCPA 2026

Bridging Care Gaps Through Frequent Patient Touchpoints

This revenue model leverages the unparalleled accessibility of community pharmacies. A nationwide cross-sectional study of Medicare beneficiaries published in JAMA Network Open revealed that patients visit community pharmacies a median of 13 times per year, compared with just 7 annual encounters with primary care physicians.³

In rural communities, where physician shortages are most severe, the disparity expands to 14 pharmacy visits against 5 physician visits. Pharmacists are ideal partners for ongoing disease management because they interact with patients far more frequently than office-based providers.

To streamline participation, NCPA and CPESN USA aligned with GamePlan Medical, an official CMS ACCESS partner. This collaboration centralizes clinical coordination, medical director oversight, and administrative support so pharmacists can focus directly on care delivery.²

Participating pharmacies work alongside primary care practices that receive co-management payments of approximately $30 per service to coordinate longitudinal care. Furthermore, updated CMS guidance allows monthly payments, rural bonus allocations, and specific billing codes that prevent duplicative fee-for-service claims while ensuring transparent financial flows.^1,2

Scope Expansion Meets Modern Pharmacy Expertise

The ACCESS program aligns with a broader national movement recognizing pharmacists as highly qualified clinical providers.^4,5

Today, pharmacists complete rigorous 4- to 6-year Doctor of Pharmacy (PharmD) degrees covering extensive pharmacology, pathology, and clinical practice areas. Policy analysts at the Cato Institute point out that pharmacists have long been overlicensed and underused despite receiving classroom training comparable with physicians. Recent legislative actions in states like Wyoming, Montana, and Colorado demonstrate growing momentum to expand prescribing authority and test-and-treat protocols.

State-level scope expansions in July 2026 highlight this accelerating shift. For example, Hawaii enacted legislation mandating that public and private health plans recognize registered pharmacists as medical providers and reimburse covered clinical services. Michigan expanded Medicaid coverage for pharmacist-delivered immunizations, testing, and contraceptive care.⁵

These state policies reinforce the national transition toward integrating pharmacy teams into multidisciplinary primary care models.^3,5

Operational Readiness and the Path Forward

Unlocking these financial and clinical opportunities requires robust practice infrastructure.⁵

Pharmacy leaders emphasize that clinical authority alone does not guarantee reimbursement unless pharmacies establish proper credentialing, taxonomy enrollments, electronic claims routing, and standardized medical coding.

By combining specialized administrative networks with established workflow support, independent pharmacies can secure sustainable revenue while improving chronic disease outcomes across diverse patient populations.² And as the ACCESS to Pharmacy Care Program is further elucidated across various US regions, the pharmacist’s reimbursement challenges may be presenting a light at the end of the tunnel, regardless of the momentum behind nationwide industry reform efforts.

READ MORE: Independent Pharmacies Remain Resilient, Essential Community Providers | NCPA 2026

REFERENCES

1. CMS issues new guidance on ACCESS model payment arrangements. HomeCare. News Release. February 18, 2026. Accessed November 3, 2026. https://www.homecaremag.com/cms-issues-new-guidance-access-model-payment-arrangements/

2. Enrollment now open for ACCESS to Pharmacy Care program. Pharmacy Times. News Release. September 14, 2026. Accessed November 3, 2026. https://www.pharmacytimes.com/view/enrollment-now-open-for-access-to-pharmacy-care-program

3. Berenbrok LA, Gabriel N, Coley KC, et al. Evaluation of frequency of encounters with primary care physicians vs visits to community pharmacies among Medicare beneficiaries. JAMA Netw Open. 2020;3(7):e209132. doi:10.1001/jamanetworkopen.2020.9132

4. Singer JA. Overlicensed and underused: rethinking pharmacy’s role in health care. Cato Institute. June 25, 2025. Accessed November 3, 2026. https://www.cato.org/blog/overlicensed-underused-rethinking-pharmacys-role-health-care

5. Cranford P. Pharmacist scope of practice keeps expanding: four major updates from July 2026. Provider CSAO. August 5, 2026. Accessed November 3, 2026. https://www.providercsao.com/post/pharmacist-scope-of-practice-keeps-expanding-four-major-updates-from-july-2026