Who PBMs are and what they do
Pharmacy benefit managers are intermediaries between insurance plans and pharmacies. They administer prescription drug benefits, maintain formularies, negotiate with manufacturers, and process claims. Three companies handle a substantial share of the prescription market in the United States. They sit between you, your insurance plan, your prescriber, and the pharmacy that fills your prescription.
PBMs are not the manufacturer. They are not the insurance company. They are not the pharmacy. They are the middle layer that decides what your pharmacy gets paid, what your copay will be, and which medications your plan covers.
How reimbursement works in practice
When a pharmacy fills your prescription, the PBM tells the pharmacy what the patient will pay (your copay) and what the PBM will pay back to the pharmacy. The pharmacy buys the medication from a wholesaler, dispenses it, counsels the patient, manages the record, and waits for the PBM payment.
For many medications, the PBM reimbursement is below what the pharmacy paid to acquire the medication. The pharmacy fills the prescription anyway, sometimes at a loss, because patients need their medications. Then months later, after the prescription has long been filled, DIR fees (direct and indirect remuneration fees) claw back additional dollars from the pharmacy based on performance metrics nobody fully controls.
Imagine running any other business where a third party tells you what you can charge, pays you below your cost on a meaningful share of transactions, then collects additional fees from you months later. That is what independent pharmacy reimbursement looks like for many of the prescriptions filled across Mississippi every day.
Why this is closing pharmacies in Mississippi
Independent pharmacies in small Mississippi towns have closed at a steady pace over the past decade. Once a community pharmacy closes, the nearest replacement is often 30 to 60 minutes away. For older adults, patients without reliable transportation, and patients on multiple medications, that distance affects whether prescriptions get filled at all.
The pattern is not driven by patients walking away. The patients are still there. The pharmacies are leaving because the economics no longer work. Margins erode year over year. Owners who have been serving their communities for decades retire without successors because no new pharmacist can make the math work. Closures cluster geographically, creating pharmacy deserts that grow each year.
What this does to your prescription
When pharmacies operate under PBM pressure, several patient facing things change.
- Staffing gets thinner. Less time per patient at the counter.
- Counseling on new medications shortens or disappears.
- Hold times for refills lengthen.
- Errors creep in when pharmacists are stretched.
- Services that used to be free, including consultations, sometimes get monetized to make up margin elsewhere.
- Some medications are sent to mail order operations that the PBM owns or partners with, regardless of whether you wanted that.
- Your local pharmacy may close entirely.
Why I am still standing
Fairview has survived because of choices made decades before I arrived and choices we make now. Dr. Kate Winborne and Mr. Larry Winborne founded Fairview in 1978 and built a model around community service, careful management, and a long horizon. When I bought the pharmacy in 2016, I inherited that foundation. We invested in services that PBMs do not pay for but that patients need. Free medication reviews. Same day delivery. Vaccinations without appointments. Statewide service for patients who live in pharmacy deserts. Wellness+, our national OTC line, which lets us serve patients beyond what PBMs control.
We pay our pharmacists and technicians as professionals because we want them to stay. We answer the phone when patients call. We do the things that build long term relationships, knowing that patients who feel cared for tend to stay for decades. That is how a pharmacy survives in 2026.
What patients can do
- Use independent pharmacies that still exist in your area. They keep going because patients stay with them.
- Transfer prescriptions to a pharmacy that takes the time to know you. Most independents accept the same insurance as the chains.
- Pay attention to who owns your mail order pharmacy. Many are owned by the same PBMs that set your insurance terms.
- Tell your state and federal representatives that PBM reform matters to you. Policy can change this.
- Ask your pharmacist questions, use the consultations, get the vaccines. Use the services that distinguish a pharmacy from a vending machine.
Why this matters past the next election cycle
If the trend continues, more Mississippi counties will lose their pharmacies. More patients will rely on mail order operations they did not choose. More older adults will drive farther for medications they need monthly. More pharmacists who trained to provide clinical care will work in conditions that do not allow them to. The country will lose something quietly that took decades to build.
Fairview is one pharmacy. We cannot solve this alone. But we can keep providing care the way it should be provided for as long as we can. And we can keep saying out loud what the patients we serve already know: this is not how pharmacy is supposed to work.
When to talk to a pharmacist
- Your local pharmacy has closed and you need a replacement.
- You have been pushed toward mail order against your preference.
- You feel your current pharmacy no longer has time for you.
- You want to use a pharmacy that has been independent and pharmacist owned since 1978.
This article is for general information only and is not a substitute for personalized medical advice. Before starting or changing any medication, including over the counter products and supplements, talk with your pharmacist or physician about your specific situation.