The Pharmacy Model Creating New Billing Pathways, Improved Recognition

With pharmacist provider status stalled in Congress, a Centers for Medicare & Medicaid Services (CMS) program known as ACCESS to Pharmacy Care now allows pharmacies enrolled in Medicare Part B to bill Medicare directly.

“Pharmacists are a trusted source, a valuable source, a source that can change outcomes, and deserve provider or rendering participant status so we can bill for the valuable services that we provide,” Mark Ey, RPh, senior vice president and chief operating officer with NCPA, told Drug Topics®.

In this week’s episode of the Over the Counter podcast, Ey joined us to explore the key details behind the ACCESS program and just how, in partnership with CMS and multiple pharmacy-focused organizations, this model could accelerate the pharmacy profession like it never has before.

Streamlining Medicare Billing and Structural Recognition

To address historical administrative hurdles, the CMS Innovation Center issued a formal statutory waiver under section 1115A(d)(1) of the Social Security Act. This waiver temporarily suspends select section 1861 provisions to permit Medicare Part B enrolled pharmacies to bill for the ACCESS Co-Management Payment (CMP) effective October 1, 2026.¹

As Ey explains, this billing implementation relies on CMS Form 855B, which is the exact enrollment form pharmacies already utilize for immunizations. By leveraging existing immunization billing channels, the ACCESS framework eliminates the need for complex medical billing software and specialized accreditation that traditionally hindered pharmacy participation in Part B.

This streamlined billing mechanism directly addresses long-standing structural barriers that have constrained community pharmacy practice. Advocates note that despite full Medicare Part B provider status for pharmacists remaining stalled in Congress, establishing rendering participant status grants long-overdue financial recognition for care services pharmacists routinely deliver.²

Academic literature emphasizes that pharmacists are specialized medication experts rather than mid-level providers, possessing advanced clinical training to optimize outcomes for complex patients managing multiple chronic conditions.

Collaborative Support and Expanding Revenue Pathways

The model is particularly vital given that more than two-thirds of Medicare beneficiaries live with at least one chronic condition, requiring continuous coordination beyond routine office visits.³

Pharmacists are uniquely positioned to bridge these care gaps because they see their patients 12 to 14 times per year, compared with primary care physicians who typically see patients only once or twice annually. Under the ACCESS framework, participating pharmacies can earn up to $100 per patient track quarterly across initial categories such as diabetes, hypertension, prediabetes, and musculoskeletal conditions.

Because many chronic disease patients qualify for 2 or 3 tracks simultaneously, a pharmacy can generate $200 to $300 per patient annually. Ey highlights that an average independent pharmacy enrolling just 50 to 200 patients could see an immediate, substantial addition to its bottom line.

Shifting Toward Outcomes and Future Scales

Beyond financial returns, the ACCESS model represents a fundamental transition from commodity-based dispensing toward value-based health care reimbursement.

Similar with expanded patient care roles authorized during the COVID-19 pandemic, this initiative rewards pharmacists for achieving measurable health improvements that reduce hospitalizations and overall medical spend. Additional clinical tracks scheduled for April of next year focus on congestive heart failure, chronic obstructive pulmonary disease, substance use disorder, smoking cessation, and behavioral health.²

CMS is also exploring expanding the program to Medicare Advantage and Medicaid plans by 2028, which could render over 50% of an average independent pharmacy's patient population eligible for outcomes-based care management.

By participating in this 10-year innovation test, pharmacists can generate robust clinical data proving that direct pharmacist engagement drives superior patient health and strengthens their indispensable role on the health care team.²

Stay tuned for weekly podcast episodes of Over the Counter powered by Drug Topics. Check out our most recent episode with Zaid Fadul, MD, FS, FAAFP, overseeing physician for the Nolla Derm pilot program. He joined to discuss his organization’s new AI-powered product and how it’s opening the door for a new future in drug delivery.

REFERENCES

1. Notice of statutory waiver to effectuate pharmacy billing of the Co-Management Payment (CMP) in the Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model. CMS. October 27, 2026. Accessed November 9, 2026. https://www.cms.gov/priorities/innovation/files/access-pharma-billing-cmp-waiver.pdf

2. Moore GD, Bradley-Baker LR, Gandhi N, et al. Pharmacists Are Not Mid-Level Providers. Am J Pharm Educ. 2022;86(3):8556. doi:10.5688/ajpe8556

3. Enrollment now open for ACCESS to Pharmacy Care program. NCPA. News Release. September 14, 2026. Accessed November 9, 2026. https://ncpa.org/newsroom/news-releases/2026/09/14/enrollment-now-open-access-pharmacy-care-program