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In 2025, medically integrated dispensing pharmacies face significant challenges, including low reimbursements, restrictive pharmacy benefit manager practices, complex therapies, regulatory barriers such as the Stark delivery law, and the Inflation Reduction Act's financial implications, necessitating urgent advocacy, reform, and collaboration to sustain equitable, patient-centered cancer care.
In 2025, medically integrated dispensing (MID) pharmacies stand at a critical crossroads, facing significant challenges that threaten their ability to provide essential care for patients with cancer. These specialized pharmacies, which combine clinical expertise with medication management, play a vital role in improving patient outcomes. However, systemic issues such as inadequate reimbursements, restrictive pharmacy benefit manager (PBM) practices, and evolving regulatory frameworks are jeopardizing their operations.
Systemic issues such as inadequate reimbursements, restrictive pharmacy benefit manager practices, and evolving regulatory frameworks may jeopardize pharmacy operations. Image Credit: © Рика Тс - stock.adobe.com
Simultaneously, the emergence of innovative cancer therapies, the impact of policy changes like the Inflation Reduction Act (IRA), and the reinterpretation of long-standing laws such as the Stark delivery law add further complexity to the landscape. Each of these factors underscores the urgent need for reform and collaboration within the health care ecosystem to sustain high-quality, patient-centered oncology care.
This article explores the pressing challenges and opportunities facing MID pharmacies in 2025, highlighting the importance of advocacy, policy reform, and strategic innovation to ensure equitable and accessible cancer treatment for all patients.
MID pharmacies are critical in improving patient outcomes by offering comprehensive medication management to cancer patients. However, in 2025, these dispensing pharmacies face mounting financial pressure due to unsustainably low reimbursement rates from certain PBMs and payers. These inadequate reimbursements often fail to cover even the costs of oral cancer medication, not to mention other personalized clinical services, such as medication adherence support, prior authorization assistance, financial assistance, and real-time care coordination. Without fair compensation, MID pharmacies risk reducing services or closing altogether, which could disrupt access to life-saving therapies for patients with cancer who have other complex conditions. Ensuring adequate and fair reimbursement for cancer medication is vital for sustaining high-quality, patient-centered care.
Only 3 PBMs control nearly 80% of all prescriptions filled in the United States, and pharmacies affiliated with the 3 largest PBMs now account for almost 70% of all specialty drug revenue.1 This vertical and horizontal PBM consolidation has resulted in increased costs to patients and the closure of independent pharmacies. To remain viable in 2025, it is more important than ever that MID pharmacies proactively engage in advocacy efforts, form strategic partnerships, and enhance data reporting to demonstrate their value in improving patients’ outcomes and lowering the cost of care. Active participation in PBM reform discussions will be crucial to securing equitable reimbursement and maintaining access to critical cancer services for vulnerable patient populations.
2025 will usher in many bispecific antibodies and other complex treatments and regimens that include oral oncolytics and infusion combinations that will offer additional opportunities and challenges to MIDs. As these complex therapies offer more life-saving options for patients with cancer, MIDs must strengthen their clinical expertise and operational efficiencies. This class of drugs brings challenges in many areas, including utilizing the inpatient and outpatient setting, managing unique adverse effects and Risk Evaluation and Mitigation Strategy requirements, managing high treatment costs coupled with low reimbursement, supporting patients who live in remote areas, and managing complex administration protocols.
At the end of the Public Health Emergency in May of 2023, the Centers for Medicare & Medicaid Services (CMS) wrongly re-interpreted the law to prohibit independent physician practice from delivering oral cancer medications via mail or other delivery services.2 The agency’s interpretation of the rule also prevents spouses, family members, or caregivers from picking up medications.2
The result has been undue and unnecessary hardship on patients already dealing with cancer and other serious diseases, forcing them to either travel to pick up their prescriptions or make use of unreliable PBM mail order specialty pharmacies. Sending the prescription out of the care of the MID facility not only puts the practice at a significant disadvantage to PBM-owned pharmacies but, more importantly, creates a severe burden on patients with cancer by blocking their access to care and creating a disparity in cancer treatment for our seniors and rural patients.
Judith Alberto, MHA, RPh, BCOP, is director of clinical initiatives at Community Oncology Alliance (COA).
Yen Nguyen, PharmD, is executive director of pharmacy at Oncology Consultants.
Jonas Congelli, RPh, is chief strategy officer at Hematology/Oncology Associates of CNY.
The IRA of 2022 includes provisions that will affect drug pricing and reimbursement for 2025.3 PBMs and payers are likely to adjust their contracts and reimbursement models in response to the IRA. This has the potential to create challenges for MIDs that may include lower reimbursements from payers and PBMs that will cut into already tight profit margins while navigating uncharted and untested territory. MIDs must wait for manufacturers to pass on the maximum fair price (MFP), creating a cash flow deficit. With the IRA imposing penalties on pharmaceutical manufacturers that increase prices above inflation rates, they could see additional cash flow constraints from fixed reimbursement rates. There is also the concern that MFP drugs could potentially be excluded from PBM formularies. While the out-of-pocket capping and Medicare prescription payment program is a win for patients, it will require additional support and education and increased administrative burden, workload, and operational costs. The downstream effect of manufacturers' response to reduced revenue will ultimately impact MIDs.
While challenges facing MIDs can seem overwhelming at times, there are many opportunities to help change the system. From education to advocacy and coalition building, there is power in our numbers. Thanks to ongoing advocacy efforts, PBM is now a well understood household name and hot-button issue for lawmakers on Capitol Hill. No longer can PBMs hide in the middle, escaping blame by shifting it onto providers, patients, and drugmakers. In addition, Congress is now asking CMS why patients can no longer get critical drugs delivered or have caregivers pick them up.
Modern cancer treatment has the potential to transform lives. But to deliver on this potential and the promise of independent community oncology—namely, the highest quality, most affordable cancer care close to home—we must foster a health care system that is accessible and equitable for all patients. The good news is that we have the tools and knowledge to achieve this dream. By working together, we can make it a reality.
