American Pharmacists Month: The Importance of Pharmacy-PBM Relationships

Pharmacy benefit manager (PBM) reform is gaining momentum nationwide, but experts caution that pharmacies, a cornerstone of community health care, must still fight to keep their PBM network relationships intact until those protections fully take hold.

“PBM reform is moving fast and it's really great to see how it's moving, how everyone is speaking about PBMs. [With] that said, reform is still ongoing,” Harini Bupathi, Esq, partner practicing in Frier Levitt’s Life Sciences litigation practice group, told Drug Topics®. “While it's rapid and it's moving fast, it might not be fast enough for some existing pharmacies. PBMs still control most of the market share and the networks today.”

Bupathi warns that pharmacy operators often underestimate the long-term value of specific PBM relationships, believing that losing a single network contract will not significantly impact immediate operations. However, major commercial health plans and state Medicaid programs frequently shift their PBM partners.

A contract that appears negligible today can quickly become vital tomorrow if a large local employer group or state agency transitions its coverage. Once a pharmacy suffers network termination, re-entering that network becomes exceptionally difficult because PBMs require extensive disclosures regarding past contract revocations.

READ MORE: American Pharmacists Month: Burnout and PBMs Remain Barriers for Community Pharmacists

Cascading Risks and Audit Pitfalls Beyond Contract Loss

The consequences of losing a network relationship extend far beyond immediate revenue drops. A single network removal frequently triggers aggressive audits, payment withholdings, and retroactive clawbacks that threaten total cash flow.¹

Furthermore, PBMs routinely share audit findings with state boards of pharmacy and federal agencies, igniting dual regulatory reviews. PBM audit defense experts from Health Law Alliance note that PBMs evaluate minor discrepancies collectively, transforming minor clerical errors or single missing signature logs into allegations of widespread noncompliance or fraud.^1,2

Legal analyses emphasize that treating an audit as a routine paperwork exercise rather than a formal enforcement action often leads directly to credentialing denials and cross-termination of affiliated pharmacy locations.

Maintaining intact PBM relationships remains vital because pharmacy benefit access directly impacts patient adherence and health outcomes. Research from PharMerica highlights that over half of American adults rely on prescription coverage for chronic conditions such as diabetes and hypertension.³

When network access is severed or drug costs spike, patient adherence drops significantly, leading to avoidable complications and costly emergency room visits. Pharmacists regularly assist patients in navigating complex benefit tiering and formulary guidelines, ensuring that individuals receive essential therapies without falling victim to prescribing cascades or cost-driven nonadherence.

Navigating Implementation Delays and Proactive Compliance Strategies

Although federal legislative milestones offer major promises for community health care, the full implementation of these protections involves a lengthy timeline.⁴

Federal legislation like the Consolidated Appropriations Act signed by President Trump mandates that Medicare Part D plans establish reasonable and relevant contract terms, designate essential retail pharmacies, and transition PBM compensation to fair-market-value bona fide service fees.⁵

However, key provisions will not take full effect until 2028 or 2029. Clinical access experts emphasize that the interval between legislative passage and regulatory enforcement is a critical runway rather than passive waiting time.^4,5

To capitalize on upcoming reforms, independent pharmacies must take proactive measures today to protect their existing networks and operational standing. Bupathi advises that compliant, good-standing pharmacies are best positioned to leverage statutory protections and challenge improper network actions without fear of retaliation.^1,4

Independent operators should perform quarterly internal self-audits to reconcile drug inventory records, review bona fide service fee language in contract renewals, and establish baseline data requests through their pharmacy services administrative organizations.

By maintaining meticulous documentation and pursuing early legal counsel during contractual disputes, community pharmacies can safeguard their network access, preserve financial stability, and continue delivering vital community services.^1,2,4

READ MORE: American Pharmacists Month Resource Center

REFERENCES

1. Nowosielski B, Bupathi H. PBM network terminations bring risks beyond lost contracts | NCPA 2026. Drug Topics. October 19, 2026. Accessed October 21, 2026. https://www.drugtopics.com/view/pbm-network-terminations-bring-risks-beyond-lost-contracts-ncpa-2026

2. Mahajan A. PBM audit defense lawyer insights: avoiding the top PBM audit traps that lead to network termination. Health Law Alliance. September 3, 2026. Accessed October 21, 2026. https://www.healthlawalliance.com/blog/pbm-audit-defense-lawyer-insights-avoiding-the-top-pbm-audit-traps-that-lead-to-network-termination

3. Pharmacy benefits: Key to health, safety, and adherence. PharMerica. September 22, 2025. Accessed October 21, 2026. https://pharmerica.com/illuminate/pharmacy-benefits-key-to-health-safety-and-adherence/

4. Chammout M. The PBM reform clock is running to 2028—Here's what independent pharmacies should do. Pharmacy Times. September 4, 2026. Accessed October 21, 2026. https://www.pharmacytimes.com/view/the-pbm-reform-clock-is-running-to-2028-here-s-what-independent-pharmacies-should-do

5. Postal S. PBM reform signed into law: what pharmacies need to know. RXinsider. February 16, 2026. Accessed October 21, 2026. https://rxinsider.com/market-buzz/pbm-reform-signed-into-law-what-pharmacies-need-to-know/