Q&A: PBMs, Community Pharmacy’s Next Move Following PBM Reform Signing

The signing of federal pharmacy benefit manager (PBM) reform in the Consolidated Appropriations Act of 2026 (HR 7148) marks a historic landmark decision in the community pharmacy landscape. However, according to many experts, further advocacy is necessary to further drive fairness and transparency in pharmacy that is often blurred by vertically integrated, large health care corporations.

“What concerns me, it all goes back to [how] these are huge, vertically integrated companies, entities.” Anne Cassity, senior vice president of government affairs at the National Community Pharmacists Association (NCPA), told Drug Topics. “I worry about them shuffling the decks, transferring different things, changing terms, calling them something else, and maybe pushing into one of their other entities.”

While HR 7148 is known as the first-of-its-kind federal PBM reform, there is still a notable number of provisions community pharmacy advocates and pharmacists alike will continue to call for in order to achieve improved sustainability on the business side of the industry.

Cassity joined us to provide deeper insights into what is next for pharmacies and PBMs amid the administration’s unprecedented move against some of the largest health care companies across the globe.

READ MORE: President Trump Signs Sweeping, Unprecedented Federal PBM Reform

Drug Topics: What kind of reaction do you think the largest PBMs will have to this new law and what do you think their next move is when the bill’s provisions begin taking effect?

Anne Cassity: Not surprisingly, their immediate reaction was to blame everything on the manufacturers. That was their statement after the bill passed. They continue to place all blame and accountability on manufacturers and say that this is just some sort of windfall for them—I disagree. Manufacturers, employers, and patient groups; I'm so thrilled that they've gotten into this fight. But that's really been over the last 5 to 7 years, because it probably started impacting them, so I understand it. This has been an issue with community pharmacy for 20 years—really 25 years, to be quite frank. PBMs’ initial reaction, once again: ‘We're not the problem, manufacturers are the problem.’ I understand why PBMs place blame on them. I don't think it does them a whole lot of good to go after independent community pharmacy.

What concerns me, it all goes back to [how] these are huge, vertically integrated companies, entities. They'll have the ability to, for lack of a better term, shape shift, if you will. If they are not allowed to do rebates, or they have to do full rebate pass-through and other things like this—or they're not allowed to do fees—I worry about them shuffling the decks, transferring different things, changing terms, calling them something else, and maybe pushing into one of their other entities.

Again, that's what makes the vertical integration so problematic. I think it will continue to be very opaque and very difficult to get behind the curtain for regulators and anyone taking a look at this. They're huge and they say they're changing their business practices, but maybe they're not. Until that's addressed, I still think there will be huge problems in terms of how they go about their business.

Drug Topics: What is next for PBM reform and further improving the financial stability of community pharmacies across the nation?

Anne Cassity: Very specifically, it's changing the pharmacy payment model, changing how PBMs reimburse pharmacies. At the end of the day, you can't continue to dispense medications and get paid below cost. That's not a viable business model. In our particular industry, we don't really have a say in what we get paid like other industries. We can't markup or change what we're paid. That really, at the end of the day, was putting pharmacies out of business. If you're spending more purchasing medications and dispensing them then you're getting paid for doing it, like I said, it's not a sustainable business model.

It's common business practice: getting paid what it costs to acquire the medication and dispense the medication. There's 2 parts to that. You have to buy the medication and then the dispensing fee, which is extraordinarily important. That covers everything from staff salaries to your mortgage or your rent, to the supplies you buy, to your power bill. That is all that makes up a dispensing fee. All we're asking for are just a transparent and fair reimbursement, nothing more or nothing less. Number one, I think that's extraordinarily important.

Also, the steering of patients by insurance companies/PBMs that own pharmacies is really, really important. I think just on its face, it's an extremely anti-competitive practice. It's unfair. It shouldn't be allowed for PBMs to steer patients to their own pharmacies, whether that be a retail pharmacy or a mail-order. What happens a lot of times is they'll say you can go to any pharmacy, but you'll pay a much higher copay if you don't go to our own pharmacy. Frankly, that's not good for patients. It's not good for plan sponsors, including government plan sponsors. We've seen the Federal Trade Commission (FTC) came out with a study—I think it was their second interim study—that said PBMs were paying themselves $7 billion collectively over what the national average drug acquisition cost is. It makes no sense to allow them to steer patients to their own pharmacy, but then also pay themselves at a much higher rate. It's bad for patients. Like I said, it's bad for employers, if they're paying higher, and [it’s bad for] government programs. Steering is extremely important.

I also mentioned earlier vertical integration, going after these vertically integrated companies. If you think about it, the argument has been in the past that vertical integration and consolidation is good. It's efficient, it brings down cost, it's efficient for consumers. Well, since we've seen this vertical integration of these companies, insurance companies buying PBMs and vice versa, and just the continued consolidation in the American health care industry, have we seen medical costs go down? No. Have we seen prescription costs go down? No. Have we seen patient access improve? No. I think that is a flawed argument.

About 2 weeks ago, there were hearings in energy and commerce, and ways and means, when you had CEOs of the 5 big insurance companies there. Interestingly enough, you have republicans and democrats alike questioning these vertically integrated companies and really saying that they should be broken up. We absolutely agree. Arkansas, last year, took the first step by passing legislation that was supported by Governor Huckabee Sanders that said that PBMs operating in the state of Arkansas cannot own pharmacies or can't be licensed by the Arkansas Board of Pharmacy. That was to address the anti-competitive practices that are occurring because you have the PBM that owns the pharmacy that owns the insurance company. We've seen some other states this legislative session who’ve introduced legislation to do the same thing. There was a bill introduced last Congress about the Senate and the House that did it at a national level. I think those talks will continue. At the end of the day, you have to make structural changes to these highly vertically integrated, consolidated companies in the health care industry.

READ MORE: What the Newest Landmark PBM Reform Means for the Pharmacy Industry

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