PUTT Blog Guest Post | Action Is the Antidote for Anxiety

10 Things Your Pharmacy Can Do Right Now to Participate in PBM Reform

State-level momentum is real - but legislation without participation is just words on paper. Here’s how to show up.

Author: Kris Rhea, MBA

Vice President of Business Development, Pharmacy Marketplace

I’ve spent the last 15 years walking into over 2,500 independent pharmacies across this country. Right now, I’ve never seen pharmacists more frustrated - or more ready to fight back.

The PBM issue isn’t new. What is new is that states are actually acting on it. Tennessee passed landmark reform. Arkansas banned PBMs from owning pharmacies. Oklahoma’s Attorney General secured a $32 million settlement from Caremark for withholding rebates. Colorado and California passed delinking laws. A TDCI audit found Caremark reimbursed CVS pharmacies 16,510% more than independent pharmacies for the same drug.

That’s not a typo.

Here’s the problem: we have legislation in nearly every state, but we don’t have participation. I’ve personally interviewed 25 state association directors and 25 enforcement agency representatives across the country. The message is the same on both sides: pharmacies are not engaging with the processes these laws were built around. 

The framework exists. Enforcement agencies have authority. Appeals processes are in place. But if pharmacies don’t show up, PBMs face zero accountability.

If the kid never tells the vice principal, the bully never gets called to the principal’s office.

PBMs are the bully. The state enforcement agency is the vice principal. And too many pharmacies are absorbing it in silence.

Action is the antidote for anxiety. When pharmacies get engaged, real data flows to state associations, patterns emerge, regulators have what they need to act, and legislators stop treating this as anecdote. It’s a business model. Let’s talk about what you can actually do.

The 10 Things

1. Read Your State’s PBM Statutes — Actually Read Them

I talk to pharmacists every week who have no idea what protections their state already has. You can’t advocate for what you don’t understand, and you can’t identify a violation if you don’t know what the law says.

NASHP maintains a tracker of PBM legislation across all 50 states. Spend an hour with it. Look at where your state stands on MAC appeal rights, anti-steering protections, spread pricing bans, reimbursement floors, and dispensing fee requirements. Then compare to states like Louisiana, Tennessee or Arkansas and ask: what’s missing, and why?

What to Do: Review your state’s PBM laws and benchmark them against leading reform states.

2. Plug Into NCPA, Your State Association and PUTT

The path has already been laid. Bill language exists. Legislative relationships exist. Coalition models exist.

What state associations need from you isn’t another complaint — it’s documented evidence that the same harmful PBM practices happening elsewhere are happening in your store, to your patients.

Volume matters. One pharmacy reporting below-cost reimbursement is a data point. Three hundred pharmacies reporting the same thing is a pattern — and patterns move legislators.

What to Do: Call your state association this week. Ask what evidence they need and which legislative priorities are active.

3. Understand What Enforcement Actually Looks Like in Your State

Many pharmacies assume enforcement agencies will investigate on their behalf. They won’t. Departments of Insurance, Attorneys General, and Boards of Pharmacy are fact-finders. They need organized, documented evidence.

Ask yourself:

• Do you know which agency regulates PBMs in your state?

• Do you know how to file a complaint?

• Do you know what documentation is required?

Most pharmacies don’t. That’s exactly why PBMs keep operating without consequence.

What to Do: Request an enforcement guide from your state association. If one doesn’t exist, help create it.

4. Submit Evidence and Make the Enforcement Agency Take a Stand

This is the most important step — and the one pharmacies skip most.

If you’ve experienced below-cost reimbursement, invalid appeal denials, unjustified clawbacks, or other statutory violations: document it and file a complaint.

Every complaint creates information. If nothing happens, you’ve identified the next advocacy challenge. If something does happen, such as audits, penalties, or consent orders, you’ve helped build a public record legislators can use to strengthen reform.

What to Do: Maintain detailed records of reimbursement discrepancies, acquisition costs, appeals, and PBM responses.

5. Network With Pharmacies in States That Have Momentum

Every state is at a different stage. The most effective learning happens pharmacist-to-pharmacist.

A Tennessee pharmacist who’s navigated the complaint process can save you months of trial and error. A pharmacy owner who’s successfully documented MAC appeal violations can share best practices you can replicate.

What to Do: Ask your state association or PUTT to connect you with peers in states further along in PBM reform.

6. Find Tools That Help You Document, Appeal, and Contribute Data

One of the biggest barriers to participation is complexity. Pharmacies often don’t know which claims qualify for appeal, which laws apply, or how to track outcomes efficiently.

Tools like Pharmacy Marketplace’s PBM Appeals Tool help automate portions of the process while aggregating data that can support broader advocacy efforts.

One appeal is a transaction. One hundred appeals across a state become evidence. Evidence becomes reform.

What to Do: Begin implementing systems in your pharmacy that simplify appeals, improve documentation, and contribute meaningful data to advocacy efforts.

7. Educate Your Most Engaged Patients

Most patients don’t know what a PBM is. When they encounter mail-order mandates, steering, or sudden disruptions to their care, they assume it’s the pharmacy’s fault. Those moments are opportunities.

Keep it simple: “PBMs are the middlemen between your insurance and your pharmacy. Sometimes their rules favor the pharmacies they own over yours.”

Patients who understand the issue are often willing to act.

What to Do: Equip your staff with plain-language talking points that explain PBMs and what patients can do about it.

8. Make Consumer Complaints Frictionless

The best time to capture a complaint is when the patient is standing at your counter. Make filing simple:

• QR codes

• Tablets with complaint portals loaded

• One-page complaint forms

• Staff assistance

The easier it is, the more complaints get filed. The more complaints filed, the stronger the evidence base becomes.

What to Do: Designate a staff member to assist patients with complaint submissions when appropriate.

9. Invite Legislators to Your Pharmacy

There is no substitute for a legislator standing in your pharmacy, talking to your patients, and seeing firsthand what’s at stake. Stories matter. Community impact matters.

When they ask, “What would you like us to do?”, that’s where your state association takes over. You provide the story. They provide the policy roadmap. Together, you create action.

What to Do: Coordinate pharmacy visits through your state association as part of a larger advocacy effort.

10. Bring Wins From Other States to Your Legislators

Legislators pay attention to what neighboring states are doing. Help them connect the dots.

• Tennessee’s FairRx Act

• Arkansas’ PBM ownership ban

• Oklahoma enforcement actions

• Delinking legislation in Colorado and California

Real-world examples make the case that reform is possible — because it’s already happening.

What to Do: Set up Google Alerts for PBM reform developments and share relevant updates with legislators and association leaders.

The Framework Exists. What’s Missing Is You.

I’ve spent a year and a half talking to state association directors, enforcement agencies, legislators, and pharmacists across this country. The message is remarkably consistent:

• The laws exist.

• The authority exists.

• The enforcement agencies want to act.

• They cannot act without evidence - and the evidence isn’t arriving at the scale it needs to.

That gap between legislation and enforcement is where pharmacies live today. Closing it won’t happen from the top down.

It will happen because enough pharmacies decide to stop absorbing the abuse and start documenting it, appealing it, and sharing it with the people who have the authority to do something about it.

Pick one item from this list. Start this week.

Federal reform doesn’t come first, it comes after enough states have proven the model is broken - and states can only prove that with data that only pharmacies can provide.