By Breck Rice, MBA

Pharmacy benefit managers (PBMs) are often discussed in terms of reimbursement rates, direct and indirect remuneration (DIR) fees, formularies, network contracts, clawbacks, and other complex elements of the prescription drug system. Those issues are important, but they can make it easy to overlook the people who experience the consequences of those decisions every day: patients and the pharmacists who care for them.

For independent community pharmacists, the impact of PBM policies is not confined to spreadsheets or financial reports. It can show up directly at the pharmacy counter, where a pharmacist may have to tell a longtime patient that a medication can no longer be filled at the pharmacy they trust.

The role of an independent pharmacy in a rural community

Dr. Fair Jones, an independent pharmacy owner in Grenada, Mississippi, has experienced that reality firsthand.

Her pharmacy has been part of the community for decades, and Jones describes the relationship between the pharmacy and its patients as being much more like a family than a traditional business relationship. The pharmacy staff knows patients well beyond their prescription histories. They know about their families, their children, surgeries, jobs, and other aspects of their lives. For many patients in this rural Mississippi community, the pharmacy is also one of the most accessible places to seek guidance about a health concern.

Patients may call or walk into the pharmacy with questions before deciding whether they need to see a physician. Sometimes they simply need someone to help them understand information they received from a doctor’s office. 

Accessibility is one of the defining characteristics of community pharmacy. But that relationship can become strained when insurance and PBM policies dictate where a prescription can be filled or how much a patient must pay.

How a $60 copay jumped to nearly $500

Jones described one particularly troubling example involving a patient with chronic obstructive pulmonary disease (COPD) who relied on an expensive brand-name inhaler. For months, the patient’s copay had been approximately $60, and the pharmacy was able to dispense the medication without taking a significant loss. Then the patient’s plan changed.

Suddenly, the copay increased to nearly $500. After investigating the situation, Jones discovered that the patient’s plan was effectively penalizing him for using the independent pharmacy. He was being directed toward a chain pharmacy or mail order.

The patient needed the medication immediately. He worked locally and did not have hundreds of dollars available for an unexpected prescription expense. Nevertheless, faced with the choice between paying the large copay or going without an inhaler he needed to breathe, he put the charge on his credit card.

Eventually, the prescription was transferred to another pharmacy where it could be obtained under the patient’s benefit structure.

What a cost-control policy looks like at the patient level

The situation illustrates an important distinction in the PBM debate. A policy designed to manage costs within a health plan can have consequences that differ significantly for patients.

In this case, the patient did not simply experience a change in price. He experienced a disruption in access and a forced change in where he received care.

When the pharmacist becomes the face of the decision

The pharmacist experienced something different but equally significant. She had to explain to a patient why the pharmacy could no longer provide a medication it had successfully provided for months.

That conversation can be difficult because patients do not always understand the complex structure behind an insurance rejection, formulary change, network restriction, or copay adjustment. From their perspective, they walked into the pharmacy they trust and were told that something that worked last month no longer works today.

The pharmacist becomes the face of a decision the pharmacist did not make.

That creates an unusual burden for independent pharmacies. They are expected to maintain the patient relationship while navigating policies established by organizations outside the pharmacy.

Why transparency only goes so far

Jones has responded by being increasingly transparent with her patients. When an insurance policy creates a problem, she tries to explain what is happening so patients understand that the issue is not necessarily the pharmacy’s decision. She also tries to give patients enough information to communicate with their employer or insurance company when appropriate.

Still, transparency does not eliminate the underlying problem. Patients still need their medications.

Balancing patient care with keeping the doors open

For independent pharmacies, the challenge is both financial and human. A pharmacy cannot indefinitely dispense medications at a price below its acquisition cost, but refusing to do so can put a trusted patient in a difficult position. The pharmacist is forced to balance the obligation to care for the patient with the financial reality of keeping the pharmacy operating.

The broader question is what happens to communities when independent pharmacies can no longer sustain themselves under conditions like these.

In rural areas, especially, the loss of an independent pharmacy can mean more than losing another retail option. It can remove a convenient and trusted point of healthcare access for people who may already have limited options.

The PBM discussion is often framed around dollars, contracts, and reimbursement formulas. But behind every reimbursement decision is a person who needs medication and a pharmacist trying to make sure that person receives it. That is the human cost that deserves a place in the conversation about PBM reform.