The Pharmacy Owner’s Guide to Navigating PBM Headaches in 2025

PBM headaches will still be around in 2025. Get your guide to making them just a wee bit better.

PBM—those three little letters have caused more headaches for independent pharmacy owners than we care to count. Just when you think you’ve figured out their latest reimbursement trick, they hit you with another clawback, new DIR fee structure, or policy that leaves you questioning why you even got into this business.

The good news?

You’re not alone, and there are ways to push back against the PBM nonsense while growing your pharmacy’s bottom line. Let’s talk about how to make 2025 the year you rise above PBM headaches and take back control of your pharmacy.

Step 1: Understand the PBM Landscape

Before we fight the beast, we need to know its nature. PBMs love to play games—whether it’s with reimbursements, DIR fees, or surprise audits—and staying informed is your first line of defense.

What to Do:

1. Know Your Contracts: Take the time to thoroughly review your contracts. Know what you should be reimbursed and how long payment terms are.
2. Stay Updated on Regulations: Laws surrounding PBMs are constantly changing, and some states have started passing pro-pharmacy legislation. Keep an eye on state and federal updates that might impact your business.
3. Join Advocacy Groups: Organizations like PUTT, NCPA, and state pharmacy associations are fighting for your rights. Join the conversation and contribute to legislative efforts.

Step 2: Minimize PBM Dependency

One of the best ways to win the PBM game? Play less of it. Building non-PBM revenue streams is crucial for reducing your pharmacy’s financial reliance on these thieving middlemen.

What to Do:

1. Expand Cash-Based Services: Offer services like weight loss programs, nutritional consultations, or wellness screenings. Patients are often willing to pay out-of-pocket for these high-value services.
2. Promote OTC Products and Supplements: Focus on products that they don’t touch, such as high-quality supplements, medical equipment, and wellness products. These items boost revenue and build customer loyalty.
3. Target Niche Markets: Consider serving markets like compounding or functional medicine. These specialized services can set you apart from competitors while bypassing PBM interference.

Step 3: Optimize Your Reimbursement Processes

If you can’t escape PBMs entirely, you can at least outsmart them. Tightening up your processes and improving efficiency can help you keep more of the money you’ve earned.

What to Do:

1. Use Technology to Your Advantage: Use software that tracks reimbursement rates and gives you the information you need to optimize billing. These tools can save you time and recover lost revenue. Our favorite is UGO. (Use code LISA to get a discount!)
2. Challenge Underpayments: Don’t let them get away with lowball reimbursements. Appeal claims that don’t meet contract terms or where you’re underwater. It’s tedious, but the dollars add up even if you don’t win them all. One of our members in New York has used their new PBM Board and has one against underwater claims.
3. Focus on High-Margin Prescriptions: Identify and promote prescriptions that provide better margins. You don’t have to fill every prescription that walks through the door, especially if it’s costing you more than you make. Some of our favorites are Oxaprozin, Nitrivia, Ziphex, and Xyzbiotic. Many high-margin products aren’t available from your typical primary wholesaler. They are only distributed through secondaries like Real Value Rx, Axia, Prodigy, Wellgistics, GRx Pharma, or Keysource.

Step 4: Educate Your Patients

PBMs may have a lot of power, but your secret weapon is your relationship with your patients. Educating them about the role PBMs play in healthcare can turn them into advocates for your pharmacy.

What to Do:

1. Explain the Problem: Many patients don’t understand how PBMs affect their medication prices and your pharmacy. Use simple language to explain why independent pharmacies are often the better option. PUTT has spectacular resources.
2. Encourage Patients to Use Their Voice: Ask patients to share their insurance struggles with local lawmakers. Grassroots efforts can lead to real change, especially when patients get involved.
3. Promote Your Value: Highlight your pharmacy’s personalized care, shorter wait times, and community support. Patients who understand your value are more likely to stay loyal and even pay cash if you dump their insurance plan.

Step 5: Advocate for PBM Reform

Change won’t happen overnight, but the fight for fair PBM practices is gaining momentum. By joining the advocacy movement, you’re helping pave the way for a better future.

What to Do:

1. Contact Your Representatives: Share your experiences with insurers and how they affect your pharmacy and your patients. Lawmakers need to hear your stories to push for reform. While change at the federal level would be awesome, you can often have more impact at the state level.
2. Support Pro-Pharmacy Legislation: Keep an eye on bills that aim to rein in these monsters, and encourage your patients to support them, too.
3. Spread Awareness: Use your blog, social media, or even local media outlets to shine a light on the PBM issue. The more people understand the problem, the closer we’ll get to solutions.

Step 6: Measure Your Progress

Navigating PBMs isn’t a “set it and forget it” task—it’s an ongoing process. Regularly evaluating your efforts will help you fine-tune your strategies and keep moving forward.

What to Do:

1. Track Your Revenue Streams: Compare PBM revenue to non-PBM revenue. Is your reliance on third-parties decreasing over time?
2. Monitor Reimbursement Rates: Are your claims being paid appropriately?
3. Do You Have The Best Contracts: Are you direct or with a PSAO? Which one is better? The answer is different for every pharmacy. Kyle at ICBN can do an amazing PSAO analytics report.
4. Set Quarterly Goals: Whether it’s growing your cash-based services or reducing negative prescriptions, track your progress and celebrate all the little wins.

Your PBM Navigation Checklist

• Review your contracts and stay updated on regulations.
• Build non-PBM revenue streams with cash services and OTC products.
• Optimize reimbursement processes and appeal underpaid claims.
• Educate patients about PBMs and promote your pharmacy’s value.
• Advocate for reform through legislative efforts.
• Regularly measure your progress and refine your strategies.

PBMs are the main reason that pharmacy owners fall out of love with pharmacy ownership. At DiversifyRx, our goal is to help you LOVE pharmacy ownership again. Inside our Pharmacy Badass University, we have a proven plan that will help you increase profits, reduce chaos, and love owning your pharmacy again.