When Employers Walk Away From the Big Three PBMs, Independent Pharmacy Has a Seat at the Table

A recent Axios report put a number on something independent pharmacists have felt in their bones for years: the grip of the three largest pharmacy benefit managers is loosening.

Axios dug into the latest "Pulse of the Purchaser" survey from the National Alliance of Healthcare Purchaser Coalitions, and the numbers tell the story. Nearly half of employers, 46% of them, have already moved to a PBM outside the big three: CVS Caremark, Optum Rx, and Express Scripts. That's up from 37% just a year ago. And of the employers still working with a big-three PBM, more than half say they're thinking about making a change in the next three years.

For the corporations footing the bill, this is a story about cost control and legal exposure. For independent and community pharmacy, it's something more hopeful. The forces pushing employers toward the exit are the same forces that have squeezed independents for the better part of a decade. When those forces reverse, independents don't just get relief. They get an opening.

Here’s how we’re reading it.

Why this is genuinely good news for community pharmacy

The middleman model that hurt independents is exactly what employers are rejecting. Look at why employers are leaving. According to the survey, they want transparency, meaning real access to claims data, and a commitment against "spread pricing," the practice of billing an employer more for a drug than the PBM pays the pharmacy that actually dispenses it. The corner pharmacy has never had any reason to be in favor of spread pricing; that is a margin for the middleman alone. When an employer spurns it, they are in effect embracing a system in which the dispensing pharmacy gets its due.

Transparent and pass-through PBMs tend to treat independents better. With alternative PBMs making inroads, there is a shift to cost-plus or NADAC-based pricing. It is a defensible way to do business, with reimbursement tied to the true cost of the drug and a fair fee for dispensing it. That's the model independents have been asking for. It replaces the guesswork and clawbacks that made it nearly impossible to know whether a prescription would be filled at a profit or a loss.

Employers value what independents already do best. The purchasers driving this shift aren't just chasing the lowest sticker price; they're chasing better management of their plans and better outcomes for their people. Local access, medication adherence, personal counseling, and the kind of relationship that keeps patients healthy and out of the hospital: that's the independent pharmacy's home turf. As benefit design gets smarter, the value of a pharmacist who actually knows the patient becomes easier to see, not harder.

The market power that felt permanent is proving anything but. For years the conventional wisdom was that the big three were simply too big to challenge. Then again, the figures put a different spin on things. To see such a marked increase in one year, with further change coming down the pike, is a message to independent pharmacies that the tide is turning. There is momentum behind it from employers who are demanding better transparency laws, not to mention the fresh PBM rules out of Congress.

Consolidation of demand meets consolidation of leverage. When the larger entities let go of their hold, there is an opportunity for the independents to gain some of their own by joining forces. That's exactly where a good GPO proves its worth. As employers spread out across a much wider mix of PBMs and networks, no independent should have to figure out alone which contracts are actually worth signing, which networks pay a fair rate, and how to get ready for the plans headed their way. That's the whole point of teaming up instead of trying to go it alone.

Clear eyes serve members better than cheerleading

Of course, none of this happens on its own, and it wouldn't be fair to our members to pretend otherwise. A few things are worth keeping in mind.

Not every "alternative" PBM is a friend to pharmacy. Leaving the big three is a step in the right direction, but it doesn't guarantee a better deal on its own. Some of the newer players are building genuinely transparent networks that respect the pharmacies in them. Others are just running the same old playbook under a nicer name. What really matters isn't the logo on the contract, it's what's inside it: the reimbursement benchmarks, the dispensing fees, any DIR-style adjustments, and how the network is set up. Every agreement is worth a hard look before anyone pops the champagne. The shift is real, but it's a trend line, not a finish line, and it will take years to fully play out.

Cost pressure isn't going anywhere. Employers still project health costs rising nearly 8% next year. That pressure gets passed around, and independents will continue to operate on thin margins in a demanding environment. A better PBM landscape eases the squeeze. It doesn't erase it.

Opportunity rewards the prepared, not the passive. The pharmacies that benefit most from this shift will be the ones already positioned to participate: credentialed, connected to the right networks, and backed by group leverage when it's time to negotiate. Waiting to see how it shakes out is the quickest way to watch that opening close.

Where AAPA members go from here

The takeaway isn't that the fight is won. It's that the direction of travel has finally turned in independent and community pharmacy's favor. That's worth building on.

Now is the moment to get contract-ready: to understand which emerging PBMs and networks actually pay fairly and to lean on the collective buying and negotiating power that levels the playing field.

That's the work we've been built for since 1996. As the big three lose their grip, independents don't have to settle for surviving the transition. With the right partner and the right strategy, this is a chance to grow into it.

AAPA is the nation's fastest-growing group purchasing organization, built and operated by independent pharmacists for independent pharmacists, delivering aggressive buying power, business insight, and advocacy that keeps community pharmacy strong.