PBM Reform Raises the Floor. Systems Raise the Ceiling

The advocacy win is a real fact.

In July, the FTC secured a settlement with CVS Caremark. Back-to-back settlements with Express Scripts and Caremark, with the Consolidated Appropriations Act of 2026 adding legislative weight, and Drug Topics covered the combination as a reshaping of transparency standards. The industry has been arguing about PBM reform for five years or longer, and the regulatory action has finally caught up to the conversation.

Independent pharmacy owners should take a moment with that. The practices that have made the operating environment difficult for the better part of a decade are being named, documented, and structurally remedied. Transparency that used to be a talking point is now a mandate. The Caremark settlement even reaches down to the counter, barring Caremark from unfairly interfering with network pharmacies that work with pharmacy hub service providers, with a monitor assigned to take complaints from pharmacies. That's worth acknowledging.

And then there's a more important question.

Now what?

Because the owners who are going to benefit most from this environment aren't the ones who were waiting for it. They're the ones who built as though it would never come.

What Reform Can't Reach

The FTC can force transparency, mandate better disclosure of drug pricing flows, and reshape how much of the margin between manufacturer and patient ends up somewhere other than the patient's benefit.

What it can't do is build patient relationships, create community visibility, or install the retention infrastructure that keeps patients who have options choosing you specifically.

Those are operator problems. And the operators who solved them before this summer's news are now in a position the reform itself can't manufacture.

The Two Patterns

Independent pharmacy owners fall into two patterns, and the gap between them is about to get expensive.

The first pattern waits for the environment to be fair enough to build in. Wait for reimbursement to improve, wait for the advocacy win, wait for the right time to start the newsletter or the referral program. The second pattern builds regardless, with attention to economics and without recklessness, but with a clear understanding that the business built in the hard environment is the business still standing when the environment improves.

Most owners responded to years of margin compression by focusing on operational survival. That was necessary. It wasn't sufficient.

The advocacy community was right that PBM practices were harmful and needed to be addressed, and they documented the problem for years. But the documentation didn't change the daily reality inside the pharmacy, it didn't attract new patients, and it didn't keep existing patients from drifting to mail order when the insurance incentive got strong enough.

The operators who grew during those years weren't waiting for the documentation to turn into a settlement. They were building patient relationships that didn't depend on what the plan said, community visibility so their name was already the one a patient knew when a choice came up, and referral systems that generated new patients through trust rather than plan design.

Those are business decisions. And business decisions made in a difficult environment are the ones that compound the most in a better one.

The owner who built a growth system through PBM compression is positioned to accelerate now that the floor is rising. The owner who waited for the floor to rise before starting to build is starting from where he was.

Mission Is Not a Growth System

I work with independent pharmacy owners who are some of the most mission-driven people I've encountered in any industry. They got into this work because they believe the local pharmacist is one of the most underutilized assets in American health care, and they're right about that. The  clinical capability is often extraordinary, and the trust a patient has with an independent pharmacist takes years to build and can't be shipped in a box.

But mission is not to be mistaken for a growth system.

The owners who grow are the ones who gave the mission structure. They built the systems that turn a good understanding of the context into visible, communicated, retained patient relationships, and they decided their patients were worth marketing to and not only worth serving.

In my own pharmacy, I mailed a monthly customer newsletter to my best customers for eighty-four straight months, through an environment nobody was reforming on my behalf. 

The Floor and the Ceiling

PBM reform is real, and it isn't the last challenge this industry will face. New plan designs are coming, along with new coverage decisions and new competitive moves from chains and mail order models with the capital to absorb conditions independents have to navigate carefully.

The owner who survives primarily on better reimbursement is still at the mercy of whoever controls the next round of payment decisions. The owner who built a patient base that chooses him on purpose, that refers neighbors, and that has been retained through every coverage change of the last three years has something the next payment decision can't reach.

PBM reform improves the floor. Growth systems raise the ceiling.

The advocacy work mattered, and it will keep mattering. What it can't tell you is whether you strengthened your positioning while you were waiting for it.

If you can't say which of the two patterns your pharmacy has been running for the last three years, that's worth knowing now, while the floor is rising and before the next round of reform changes the terms again. The Independent Pharmacy Growth Index shows you where your growth system is holding and where it's leaking, across attraction, referrals, retention, and the places growth stalls while an owner waits for conditions to improve. It takes a few minutes, and it tells you the truth.

Mike Hodges

Founder, Pharmacy Breakthroughs Mastermind

Former independent pharmacy owner