Pharmacies Face Persistent MFP Cash Crunch Amid PBM, 340B Shifts

In the first year of Medicare’s negotiated drug prices, most pharmacies have waited at least 22 days to be repaid for maximum fair price (MFP) drugs. Some, however, waited over a month, a gap that Allison Schneider, MPH, director at ADVI Health, says will widen as higher-cost drugs join the Medicare Drug Price Negotiation Program (MDPNP).

“When we're talking about this cash flow crunch, it's that waiting period between purchasing a drug and then waiting to actually get the refund and be made whole for the product,” Schneider tells Drug Topics®. “That can be a really substantial amount of money, depending on the product in question. I think we're likely to see that continue to happen even more with future years of negotiation.”

In this week’s episode, Schneider explains how new federal pharmacy benefit manager (PBM) reform, Federal Trade Commission (FTC) settlements with major PBMs, and state laws further restricting PBMs are all landing at once. With these ongoing developments occurring at the same time as the initial rollout of the MDPNP, keeping a pharmacy’s business financially viable has been met with unprecedented hurdles throughout 2026.

READ MORE: FAQ: Policies for Pharmacists to Track Heading into 2026 Midterms

As more negotiations are set to take effect in the new year, as well as more coming on an annual basis, it’s never a better time for pharmacists to stay in the know on sweeping changes to federal drug supply chain policies.

Operational Friction and Payment Delays

Under the MDPNP, pharmacies face significant upfront cash flow losses because PBMs reimburse claims at or below the negotiated MFP while pharmacies purchase inventory at full wholesale acquisition cost (WAC).¹

Data from the National Community Pharmacists Association (NCPA) indicates that most independent pharmacy owners wait at least 22 days for manufacturer backend refunds, with 20% waiting over 28 days. Furthermore, long-term care (LTC) pharmacy leaders warn that multi-step claims routing through the Medicare Transaction Facilitator (MTF) create severe payment lags, threatening 60% of specialized facilities with closures.^2,3

These cash flow hurdles will escalate as the Centers for Medicare and Medicaid Services (CMS) implements negotiated prices for 15 additional high-cost cancer and chronic disease medications in 2027, affecting 5.3 million Medicare beneficiaries.⁴

Schneider highlights that incorporating expensive specialty therapies means pharmacies will need to float thousands of dollars per prescription.

Federal and State Reform Landscape

These reimbursement challenges coincide with sweeping policy changes across the PBM market.

Statutory updates in the Consolidated Appropriations Act of 2026 mandate PBM compensation delinking in Medicare Part D, while new state laws in Florida, Kansas, and Tennessee prohibit spread pricing, enforce reimbursement floors, and restrict common ownership between PBMs and pharmacies.⁵

Schneider notes that although regulatory oversight creates vital long-term protections, adjusting to overlapping federal and state compliance rules creates immediate operational friction.

The 340B Intersection and Market Adaptation

Expanding Medicare price negotiations also creates logistical friction within the 340B Drug Discount Program due to statutory rules prohibiting duplicate discounts on negotiated drugs. Federal initiatives to institute post-sale rebate models for 340B claims have faced continuous administrative revisions and court challenges.⁶

Avalere research demonstrates that 34% of Medicare prescriptions subject to price negotiations are filled at independent or franchise pharmacies, underscoring the broad exposure of community providers.¹

Pharmacy owners are relying on automated software tools and digital tracking platforms to monitor claims adjudication, verify remittance files, and safeguard business margins through this rapid transition.

“This is just the beginning of additional changes made under the Inflation Reduction Act through MDNP,” concluded RedSail Technologies.¹ “It’s important to stay up to date on these new regulations to understand what changes you need to implement and how they will affect your business.”

Stay tuned for weekly podcast episodes of Over the Counter powered by Drug Topics. Check out our most recent episode with Rita King, who applied her extensive experience in the medical device market toward the growing evidence of AI’s use across patient-friendly technology coming in and out of the pharmacy.

REFERENCES

1. Maassen L. Medicare Drug Price Negotiation Program (MDPNP): the effect on independent pharmacies. RedSail Technologies. January 13, 2026. Accessed October 28, 2026. https://www.redsailtechnologies.com/blog/medicare-drug-price-negotiation-program-mdpnp

2. NCPA shares survey results with CMS showing MFP refund delays. NCPA. News Release. February 27, 2026. Accessed October 28, 2026. https://ncpa.org/newsroom/qam/2026/02/27/ncpa-shares-survey-results-cms-showing-mfp-refund-delays

3. Pharmacies to face low cash flow for MFP drugs until fixes emerge. SCPC. February 25, 2026. Accessed October 28, 2026. https://seniorcarepharmacies.org/pharmacies-to-face-low-cash-flow-for-mfp-drugs-until-fixes-emerge/

4. CMS delivers savings for seniors on 15 major drugs for cancer and chronic disease. CMS. News Release. November 25, 2025. Accessed October 28, 2026. https://www.cms.gov/newsroom/press-releases/cms-delivers-savings-seniors-15-major-drugs-cancer-chronic-disease

5. Carnegie TC, Keller BA, Dwyer TE, et al. PBM policy and legislative update – fall 2026. Mintz. 2026. Accessed October 28, 2026. https://www.mintz.com/insights-center/viewpoints/2026-10-01-pbm-policy-and-legislative-update-fall-2026

6. Rogers HA, Wreschnig LA. Overview of the 340B Drug Discount Program. Congress.gov. September 10, 2026. Accessed October 28, 2026. https://www.congress.gov/crs-product/IF13311