As attorneys representing community pharmacies nationwide, Frier Levitt had the opportunity to attend and exhibit at this year’s National Community Pharmacists Association (NCPA) Annual Conference in New Orleans. Over the course of several days, attorneys Harini Bupathi, Esq., and Eric Knowles, Esq., met with dozens of pharmacy owners, operators, and industry leaders. Despite differences in geography, payer mix, and business models, the conversations at NCPA centered around three themes—each reflecting the very real pressures and opportunities shaping today’s independent pharmacy landscape.
In this article, we break down the three biggest trends community pharmacy owners raised during NCPA 2025:
- Reimbursement Challenges and Emerging Contract Strategies
- Escalating PBM Activity and New Audit Tactics
- Board of Pharmacy Scrutiny and the Rising Compliance Burden
These themes should serve as both a reflection of the current environment and a roadmap for where pharmacies need to focus in the year ahead.
Reimbursement Rates: The Most Pressing Challenge in Community Pharmacy
It was immediately clear at NCPA that reimbursement remains the number one concern for community pharmacy owners. The shift to NADAC-based reimbursement in several states, persistent below-cost payments, unpredictable GER/BER reconciliations, and the continuing impact of spread pricing and effective rate contracts have left many pharmacies operating on razor-thin margins.
Declining Reimbursement Is Now the “New Normal”
Pharmacy owners repeatedly shared examples of claim payments that were significantly below invoice cost, particularly for generics and for high-cost specialty-lite medications increasingly being pushed into open networks. Even pharmacies in states with “pharmacy choice” laws or transparency reforms reported ongoing issues with:
- MAC pricing manipulations
- Retroactive adjustments through effective rate clawbacks
- Plan-level exclusions that steer patients to PBM-affiliated pharmacies
- Inconsistent NADAC updates that fail to reflect true acquisition cost
While many owners at the conference expressed frustration, they also shared a sense of realism: reimbursement isn’t improving on its own. Pharmacies are increasingly pivoting toward contracting strategies that reflect today’s reimbursement reality.
PBM Audits: Aggressive, Expanding, and Increasingly Unpredictable
PBM audits were the second most frequently discussed issue at NCPA—unsurprising given the significant uptick in audit activity across all major PBMs, including OptumRx, Express Scripts, CVS Caremark, and Humana.
New Audit Tactics and Red Flags
Pharmacy owners reported newer audit trends that reflect a more aggressive stance by PBMs:
- Inventory audits, including the review of pharmacies’ purchase and dispensing records, as a standard process of every audit and/or investigation, leading to chargebacks over minor documentation and recordkeeping issues
- Common, inaccurate allegations of patient and prescriber denials, despite pharmacies maintaining significant documentation in support of patient and prescriber authorization prior to dispensing
- Hard-line position on DAW and prescriber documentation, even when clinically appropriate
- Use of claims-level data to flag concurrent prescribing anomalies, including tracking the distance of patients and prescribers, high-cost medications, etc.
- Heightened scrutiny of controlled substances, causing some manufacturers to block pharmacies from purchasing their medications
Many pharmacies also noted that PBMs are leaning heavily on technical denial points such as signature logs, refill documentation, prescriber communications to justify substantial recoupments even where no fraud, waste, or abuse exists.
Audit Defense Is Becoming a Core Survival Skill
The overriding sentiment at NCPA was clear: audits are no longer episodic; they are constant. Pharmacies are increasingly seeking legal guidance on responding to audit findings strategically, ensuring documentation is audit-ready, challenging improper recoupments, appealing termination notices, and addressing PBM concerns proactively before they escalate
Key takeaway: PBM audits have evolved into a primary revenue-recovery tool for PBMs. Pharmacies cannot afford to improvise, they need strong compliance infrastructure and experienced counsel to protect their reimbursement and network status. Pharmacies should consider downloading our PBM Audit Checklist to stay audit-ready.
Board of Pharmacy Issues: Heightened Enforcement and More Complex Regulations
Another striking theme at NCPA was the frequency with which board of pharmacy enforcement issues surfaced in owner discussions. Pharmacy leaders consistently described an environment of heightened scrutiny from state boards, with particular emphasis on compounding practices, documentation standards, and the evolving scope of pharmacist responsibilities. Owners cited increasingly active oversight in states such as California, Ohio, Texas, Florida, and New York, with recurring focus areas including sterile and non-sterile compounding findings, collaborative practice agreement compliance, pharmacist-in-charge accountability and staffing adherence, telepharmacy supervision, and controlled substance inventory reconciliation discrepancies.
Across markets, pharmacies described more frequent and more rigorous inspections, accompanied by granular corrective action plans and compressed timelines for response. Many owners observed that operational practices considered acceptable a few years ago would likely fail under today’s standards.
The key takeaway is clear: board of pharmacy compliance is not peripheral. It must be embedded into daily workflows and continuously reinforced, rather than treated as a discrete, one-time effort.
Final Thoughts: The Road Ahead for Community Pharmacies
This year’s NCPA meeting reinforced something that many pharmacy owners already know: community pharmacies are under pressure from every direction including reimbursement, PBMs, regulators, wholesalers, and even manufacturers. But the conference also highlighted something equally important: independent pharmacies remain resilient, entrepreneurial, and deeply committed to serving their communities.
As our firm continues to represent community retail pharmacies across the country, we remain focused on helping owners navigate:
- Contracting strategies to improve reimbursement
- Defending against PBM audits and improper recoupments
- Building strong compliance frameworks to satisfy state boards
- Defending pharmacies in adverse board of pharmacy actions
- Structuring alternative revenue models
- Expanding clinical services in a compliant manner
- Protecting pharmacies from unfair payer practices
For pharmacy owners looking to stay ahead of these evolving trends or seeking guidance on any of these issues, we welcome the opportunity to connect and explore how we can support your needs.
