There are dozens of examples daily at most every community retail pharmacy.  These are some examples to showcase the commonality of items, with specific exact dollar values and what these medications are for.  EVERY insurance plan is doing this to one or more medication, to most every pharmacy, on a regular basis.  No other industry sells product below their cost on a regular, daily basis and is expected to do such, while also being blamed for being the problem for an industry… *Ozempic 2mg/3mL Pen: Pharmacy cost = $977.63     Patient CoPayment = $0.00     CareMark PBM Payment = $891.94     Pharmacy loss = $85.69 plus cost to dispense (payroll, electricity, insurance, software, etc.)   RX9844 10/3/2025, Missouri     Medicare Diabetic Treatment *Lubiprostone (generic Amitiza) 8mcg capsule: Pharmacy cost = $238.11     Patient CoPayment = $47.00     Humana Payment = $7.30     Pharmacy loss = $183.81 plus cost to dispense (payroll, electricity, insurance, software, etc.)   RX1938 3/12/2025, Missouri     Medicare Plan: Chronic Drug-Induced Constipation Treatment *Invega 234mg/1.5mL Syringe: Pharmacy cost = $3,497.77     Patient CoPayment = $0.00     Medicaid Payment = $3,441.05     Pharmacy loss = $56.72 plus cost to dispense (payroll, electricity, insurance, software, etc.)   RX8221 8/25/2025, Missouri     Medicaid Plan: Long-Acting

*Patient fills and picks up 8 medications regularly through retail community pharmacy.  After 2 fills of Humalog, is told now must use mail-order facility or pay 100% out-of-pocket for medication.  Patient cannot get an override or authorization to keep refrigerated insulin therapy at local community pharmacy, is required to use Express Scripts mail order for TriCare benefit.     Missouri, 9/12/2025 *Medicare widow fills 11 prescriptions for diabetes, high blood pressure, cholesterol, and depression on a limited income but is able to afford with help from secondary insurance option through state assistance program.  PBM CareMark recognizes fills at local community pharmacy and sends patient notifications to complete a paper form and send back signed to continue receiving medication, but through CVS/CareMark mail-order.  Patient is confused with letter, brings to pharmacy to inquire, and is angered that the paper is misleading, attempting to get patient to send medications to mail-order pharmacy instead of using local retail pharmacy option.     Missouri, 2/8/2025 *Patient is reviewing prescription benefits for Medicare options during open enrollment.  Finds cheapest overall plan is WellCare Medicare Part D plan at choice community retail pharmacy.  Insurance broker signs patient up for this plan, and upon filling prescriptions receives a letter

*Most pharmacies today exist with a relationship into what is known as a Pharmacy Services Administrative Organization, or PSAO, that helps “negotiate” contract terms with PBM’s.  Most “negotiations” today exist as a review of what is given to the PSAO, and whether the PSAO feels members can financially sustain such a contract.  Then, contracts are either accepted or refused.   *Common PSAO refused contracts are then offered to individual pharmacies, attempting to make the PSAO sound as if they are the non-negotiators in the common mix.  Pharmacies are told if they do not sign, they simply lose access to any patient with that parent PBM’s plan(s), and too many unfortunately sign anyhow out of fear of not being able to take care of their community.  This often leads to numerous of these losses on prescriptions, which has led to numerous pharmacy bankruptcies and closures. *PBM’s continue to “offer” contracts that have so much legal language, numerous possible payment models (AWP-minus, MAC-based, and cost-plus; each may vary by Brand VS Generic or drug category types, day supply, etc.), and withhold the potential to change from one payment model per drug as best fits the PBM’s desires at any given time.  Pharmacies dispense

*PBM’s are one of the few organizations that can be asked for information and tell such requestor to “take a hike” on a regular basis.   *Rules continue to change with the PBM’s, continuing to add to the confusion and complexity in reviewing these plans and policies, as well as typically only benefiting the bottom-line of these PBM’s. *All too commonly, plan sponsors (including employers) do not have full transparency to expenditures with the PBM’s, and end up actually over-paying for medications that are reimbursed partially with manufacturer rebates.  These rebates were designed to help reduce overall drug costs, and all-too-often end up partially or completely in the PBM’s pockets rather than the plan sponsor, pharmacy, or patient.  Patient’s typically pay high out-of-pocket expense through deductible or high-copay values, plan sponsors pay the difference plus administrative fees to PBM’s, patients pay premiums to plan sponsors to the PBM, and pharmacies often aren’t reimbursed 100% of necessary costs of medication & overhead costs.  *A recent legal case involving a large, self-insured employer, found a court dismissed claims tied to prescription drug pricing after concluding that alleged point-of-sale overpayments did not constitute injury when viewed in the context of overall plan benefits. The

*One large employer group underwrote a health insurance policy with prescription coverage for their 300+ employees.  The employees found upon attempts to use the policy that the CareMark policy required them to either pay out-of-pocket or utilize a CVS/CareMark pharmacy (mail order, or nearly 100-mile average for employees to the nearest physical store). *PBM’s hold costs out of pharmacy dispensing payments based upon patient adherence.  In other words, if a doctor writes a prescription for blood pressure medication, and the medication is not tolerated after 6 months and needs changed, the pharmacy will be penalized for the patient not picking up the medication for future periods of time until the PBM recognizes the medication is no longer taken due to months of not being filled.  Pharmacy & prescriber cannot inform PBM of discontinuation to effect any difference in reimbursement.  This is also an average across all patients filling at the pharmacy for the particular drug classification (for instance, all patients on specific drug class of high blood pressure treatments or diabetes non-insulin treatments).  Pharmacies are not allowed to enforce specific patient filling habits, nor do they want to force patients to do so, and numerous factors can affect fill rates.