How PBMs Impede Pharmacists’ Ability to Perform Clinical Services | APhA 2025
Antonio Ciaccia, President of 3 Axis Advisors, led a discussion on pharmacy benefit manager reform and how the inability to pass legislation has led to increased financial hardships in community pharmacy.
With the current prescription drug model existing in the US, pharmacists rely too heavily on their margins dispensing medications to reach financial stability. However, as pharmacy benefit managers (PBMs) continue to steer patients toward their affiliated pharmacies, opportunities for sustainability are dwindling, leading experts to believe that legislative reform is the only solution.
To address the ongoing narratives regarding PBMs and pharmacists, Antonio Ciaccia, President of 3 Axis Advisors, hosted a session at the American Pharmacists Association 2025 Annual Meeting and Exposition titled We Gotta Fight for Our Right to Partake: An Update on PBM Reform.
He discussed PBM pressures and how they have impacted pharmacy in the past 10 years. He touched on the previous, current, and future state of the pharmacy industry and provided a detailed look into what’s being done to address these issues on both the clinical and federal levels.
PBMs are typically underpaying pharmacies for the medications they dispense while overpaying companies and subsidiaries affiliated with major PBMs. | image credit: Orawan / stock.adobe.com
“The assembly-line culture in pharmacy is increasingly difficult to interrupt with new time-consuming clinical services, especially without a payment mechanism for them,” said Ciaccia.1 “Pharmacists, meanwhile, face increasing debt, dwindling employment options, growing burnout rates, lessened job satisfaction, and increasing patient challenges.”
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He introduced the topic by explaining the timeline of when PBMs came to light in the general public’s perspective. Their ability to stay anonymous, as Ciaccia stated, was first disrupted in 2016 when inflated prices for EpiPens was called into question. That controversy then transitioned into inflated insulin prices in 2017 and 2018, leading a collective curiosity for how exactly prescription drugs are priced in the US.
“These were very hot topics,” he continued.1 “You had arguments over maximum allowable costs (MACs), which is essentially the subjective pricing tool that a PBM uses to assign a value to a multi-source generic drug. The concept being that, let's say this was a room of all generic drugmakers and we're all making the same product. Well, if I'm the PBM or the payer, I shouldn't pay based upon your price, if it's 5 bucks, or your price based on if it was 4 bucks. If there's another supplier who's selling it for $3, we the payer should have the flexibility to pay the lower price and not have to pay the one that the pharmacy just all of a sudden chose.”
Ciaccia claims that the power PBMs have to subjectively assign prices to drugs has allowed them to significantly overpay or under pay. And as many experts have seen throughout various reports, they are typically underpaying pharmacies for the medications they dispense while overpaying companies and subsidiaries affiliated with major PBMs.
He then delved into his own experience with the Ohio Pharmacists Association and the unique Medicaid provisions that further allow PBMs to continue their practices. He mentioned his team’s uncovering of spread pricing, where PBMs simply “buy low, sell high, and pocket the difference” in Medicaid Managed Care programs.1
Subsequently, after spread pricing was uncovered and banned in Ohio, the PBMs pivoted and began issuing direct and indirect renumeration (DIR) fees. “Under the new world where spread pricing was banned, they paid the pharmacy $11, even though the contract with the pharmacy said they would only deserve $5. They billed the $11, paid the $11, and then a year later, they came back to the pharmacies and said, ‘Oops, overpaid.’”
Finally, he then looked to PBM reform and what is currently being done to regulate the most lucrative PBMs in the industry. He mentioned the PBM Transparency Act, 2 separate bills banning spread pricing, the Protecting Patients Against PBM Abuses Act, and the PBM Accountability Act, among many others circulating in Congress. All designed to push back against PBM practices, these provisions will increase pricing transparency, correct reimbursement issues for pharmacists, ban several PBM practices that some see as illegal or egregiously unethical, and so much more.
However, the main task at hand for those looking to recorrect how PBMs are viewed in the US is simply advocating for reform and highlighting the fact that the pharmacy industry is in turmoil because of PBM oversight.
“In general, pharmacies are over relying on dispensing margins as their primary means of sustainability and profitability. Those margins are being disproportionately steered to PBM-affiliated pharmacists. Traditional pharmacies are stuck with more and more underwater claims and less overpaid claims over time. The pressures of pharmacy are eroding access, pharmacy resources, and the overall standard of care,” he concluded.1
