Independent pharmacy reimbursement: how often do PBMs pay below cost?
PBMs often pay independent pharmacies less than the drug cost them to buy. In an NCPA survey, more than half of independent pharmacy owners said Medicare Part D plans paid them less than they paid for the drug on at least 3 out of every 10 prescriptions.
Here is what that looks like at the counter. Say you paid $40 for a bottle. You fill the prescription, the claim comes back, and the plan pays you $35. You have lost $5 before you count your staff's time. And you fill it anyway, because your patient needs it.
A year later, it had not let up. In NCPA's next survey, 4 in 10 owners said this happened on more than 40% of their Part D prescriptions. And 96.5% said Part D payments were putting their business at risk.
NCPA's yearly report on independent pharmacies shows the result. In 2024, independent pharmacies had their highest sales in 10 years. Their drug costs were the highest, too. So their gross profit was the lowest in 10 years. More money came in, and less of it stayed.
The plan sets the price, not you, and working harder will not change it. So the rest of this article covers the money you can control. First, a quick look at the new federal law, because a lot of owners are hoping it fixes this.
PBM reform: will the new federal law fix independent pharmacy reimbursement?
The federal PBM reform law passed in early 2026 does not raise what Medicare drug plans pay your pharmacy. It changes some of the rules, and most of those changes do not start until 2028 or 2029.
Here is what the law does:
Starting in 2029: Medicare drug plans have to let any pharmacy into their network if it accepts their standard contract. The law says those contracts have to be "reasonable and relevant."
Starting in 2028: PBMs get paid a flat fee for their work. Their pay can no longer rise when drug prices rise.
By April 2027: Medicare has to study whether drug plans pay pharmacies enough to cover the drug and the cost of filling the prescription.
That study is a good sign, because it asks the question you already deal with every day. But a study is not a raise. Nothing in the law pays you more today.
There was also a change in 2024. Before that, plans could take fees back from you months after they paid a claim. Since January 2024, those fees have to come off at the time of the sale. That ended the surprise fees months later. It did not raise what you get paid.
Staying up to date on PBM reform is important, but you cannot wait until 2029. So let's look at what you can do today to grow revenue in your pharmacy, without a middleman setting your price.
Pharmacy clinical services: which revenue does an independent pharmacy control?
The revenue an independent pharmacy controls best is clinical services it bills for directly, and vaccines are the clearest example. With vaccines, the payment rate is published before you give the shot, and you decide how many patients you reach.
Compare that to a prescription. When you fill a prescription, you find out what you were paid after the claim comes back. When you give a Medicare patient a flu, pneumonia or hepatitis B shot, you know before you start. Medicare pays about $35 for giving the shot, plus a separate payment for the vaccine itself. That $35 is money coming in, before you pay for your staff's time.
More than 9 in 10 independent pharmacies already give flu shots. So for most owners, this is not a new service to build. It is a service to do more of. We walk through the full vaccine numbers in How Independent Pharmacies Turn Vaccines Into a Revenue Engine.
Other services can work too, with limits:
Medication therapy management (MTM): for Medicare patients, the drug plan sets what it pays you. You do not set the price, but you decide how many reviews you do.
Testing and treating, like flu or strep: what a pharmacist is allowed to do depends on your state's laws.
The right services depend on your state and your patients. But every one of them needs your pharmacist's time. At most independent pharmacies, that time is what runs out first.
Pharmacist time: where do an independent pharmacist's hours go?
Independent pharmacists spend about 72% of their work week on dispensing and about 13% on other patient care, according to the 2022 National Pharmacist Workforce Study. Vaccines, medication reviews and testing all come out of that 13%.
Picture a normal afternoon. Your pharmacist is explaining a new blood thinner to a patient. The phone rings. A tech walks over: the caller wants to know if her refill is ready. Your pharmacist answers, then turns back and tries to pick up where they left off.
That happens all day. In a study of independent pharmacies, staff were interrupted 7 to 8 times an hour, and 43% of those interruptions came from patients.
Most of what patients call about is routine. Across the calls VOXO's Pharmacy AI Agent handles for independent pharmacies, about 4 in 5 patient requests are routine: refills, "is my prescription ready," pickup or delivery, and questions about the store.
Those calls matter. Every one is a patient who needs an answer. But none of them need a pharmacist to give the answer.
Every hour of routine calls you take off your pharmacist is an hour they can spend on vaccines, medication reviews or the patient at the counter, work that can add revenue back into your pharmacy. You decide where that hour goes.
How VOXO is helping independent pharmacies get pharmacist time back and make more money
The VOXO Pharmacy AI Agent answers an independent pharmacy's routine calls, day or night, and puts refill requests directly into their PMS. Nobody on your team has to type them in.
Since we launched it, the Agent has handled more than 1.39 million calls for independent pharmacies. It has sent more than 367,000 refill requests into their pharmacy systems. And it has taken roughly 24,000 hours of phone time off their teams.
The Agent can also make calls. The VOXO Appointment Setter calls patients who are due for a vaccine and books them on your calendar, with the right staff member assigned. Vaccine appointments are live today, and more appointment types are coming next.
Clinical questions always go to your pharmacist. If a patient asks about dosing, side effects, drug interactions or anything that sounds like medical advice, the Agent sends the call to a licensed pharmacist. That is built into the Agent, and it cannot be turned off.
The bottom line
PBMs set what you get paid for a prescription, and on a large share of prescriptions they set it below what the drug cost you. You cannot out-work a price someone else sets.
The money you can grow is in two places: services you bill for yourself, like vaccines, and the hours your pharmacist gets back when someone else handles the routine calls.
Both start with the same step: take the routine calls off your pharmacist.
How VOXO helps you find the hours
Start with your own numbers: how many calls your pharmacy gets each week, how many of them are routine, and what your pharmacist would do with that time back. VOXO answers the routine calls, and the Appointment Setter fills your calendar with vaccine visits.
Book a 30-minute demo and we will show you how many pharmacist hours your phones take each week.
Frequently asked questions
What share of independent pharmacies are paid below cost by PBMs?
More than half. In NCPA's February 2024 survey of independent pharmacy owners and managers, more than half said Medicare Part D plans paid them less than the drug cost on at least 3 out of every 10 prescriptions. In NCPA's January 2025 survey, 40.8% said they were paid below the drug's cost on more than 40% of their Part D prescriptions, and 29.2% said it happened on half or more. Both surveys cover Medicare Part D only.
Did the 2026 federal PBM reform law raise pharmacy reimbursement?
No. The Consolidated Appropriations Act, 2026 does not set a minimum payment to pharmacies. For Medicare Part D, it requires drug plans to let any pharmacy that accepts their standard contract into their network starting in 2029, and requires those contracts to be "reasonable and relevant." Starting in 2028, PBMs can no longer be paid based on drug prices. The law also requires Medicare to study, by April 1, 2027, whether drug plans pay pharmacies enough to cover the drug and the cost of dispensing it.
How much does Medicare pay a pharmacy to give a flu shot?
For the 2026 to 2027 season, Medicare pays a pharmacy $34.62 for giving a flu, pneumococcal or hepatitis B shot, and $40.98 when the shot is given in the patient's home. Medicare pays for the vaccine itself separately. Rates are adjusted by location, and commercial plans set their own.
Who sets the fee for Medicare medication therapy management?
The Medicare drug plan sets the fee it pays pharmacists for medication therapy management. The pharmacy does not set it, and neither does Medicare. For 2026, a patient qualifies for a plan's MTM program based on their chronic conditions, how many Part D drugs they take, and expected yearly Part D drug costs of at least $1,276.
How much of an independent pharmacist's time goes to dispensing?
About 72%. In the 2022 National Pharmacist Workforce Study, independent pharmacists said they spend about 72% of their work week on dispensing and about 13% on other patient care. Pharmacists at chain pharmacies said about 76% and 10%.
Does an AI phone agent answer clinical questions for the pharmacy?
No. VOXO's Pharmacy AI Agent handles routine calls, like refill requests, whether a prescription is ready, pickup and delivery, and store hours. Questions about dosing, drug interactions, side effects, or anything that sounds like medical advice go to a licensed pharmacist every time, and that cannot be turned off.
