TRICARE and the Fight for Military Pharmacy Access | PBM Reform with APCI

The PBM Reform Podcast, sponsored by APCI, welcomes John Vinson, PharmD, Chief Executive Officer of the Arkansas Pharmacists Association, for a timely conversation with host Greg Reybold about the management of the TRICARE pharmacy benefit. Express Scripts administers pharmacy benefits for TRICARE, the Department of Defense healthcare program serving more than 9 million active-duty service members, military retirees, and family members. In fiscal year 2023 alone, TRICARE spent more than $8 billion on prescription medications. Greg and John examine concerns surrounding Express Scripts’ administration of the program, including shrinking pharmacy networks, reduced patient choice, questionable contractor reporting, specialty-drug delivery oversight, and the consequences for independent and rural pharmacies. A 2025 Government Accountability Office investigation found that: TRICARE’s minimum network requirement fell from 50,000 to 35,000 pharmacies. The network had approximately 13,165 fewer pharmacies in late 2024 than in late 2022. An estimated 380,000 beneficiaries may have been forced to find another pharmacy. The Defense Health Agency relied heavily on contractor-submitted reports that contained inaccuracies. DHA had not consistently audited the data used to evaluate beneficiary access. GAO’s two corrective recommendations remain open as of August 2026, although DHA has begun adding reporting and auditing requirements. The episode also addresses higher 2026 prescription copayments. For most non-active-duty beneficiaries, home-delivery copays are now $14 for generic formulary drugs, $44 for brand-name drugs, and $85 for non-formulary medications. At retail network pharmacies, the corresponding 30-day copays are $16, $48, and $85. Greg and John discuss whether PBM-driven network reductions represent true savings—or simply transfer costs, inconvenience, and access barriers to military families and the community pharmacies serving them. Key discussion points Express Scripts’ role in administering the TRICARE pharmacy benefit Pharmacy network contraction and beneficiary disruption Access challenges facing rural communities and military families Inaccurate contractor data and insufficient federal oversight Specialty-pharmacy delivery and monitoring concerns Rising 2026 copayments and pressure toward mail order Arkansas’ leadership in challenging PBM vertical integration The need for transparency, accountability, adequate reimbursement, and patient choice Important clarification: TRICARE is administered by the Department of Defense and is distinct from healthcare and pharmacy services operated by the Department of Veterans Affairs. Sponsored by APCI — American Pharmacy Cooperative, Inc. Sources: U. S. Government Accountability Office, TRICARE’s 2026 pharmacy-benefit update, official 2026–2027 pharmacy costs.

• 0:05Speaker 00

  You are listening to the global network of podcasters dedicated to the pharmacy profession. Welcome to the pharmacy podcast network.

• 0:29Speaker 01

  Hey, welcome back to the PBM Reform Podcast brought to you by APCI. If you don't know this listener, go ahead and search PBM Reform Podcast in your Google. Go ask Alexa about it. This is the number one podcast in the space of PBM Reform with thousands and thousands of listeners per episode. We have episodes that have exceeded 10,000 downloads and listeners. Episodes like the pharmacist's fight back act that was live on Capitol Hill that we did a recording with Greg. Greg, this show has just exploded since you guys have been helping. I want to give a shout out to the APCI team.

• 1:13Speaker 01

  Thank you so much for your support of the PBM Reform Podcast. Greg, take it away.

• 1:19Speaker 02

  Awesome. Well, excited. We got, we got a great guest for this week's or this month's episode and one for folks who follow pharmacy closely, who follow PBM Reform closely and follow really just, I would say, healthcare policy closely. This, this name will be really familiar, but we have John Vincent, who is the CEO of the Arkansas Pharmacy Association. John, thank you so, so much for joining us. And I think, is this your first time on this podcast? If so, that's crazy because we, we, you know, we, we sure talk enough.

• 1:52Speaker 03

  I've been on before. It's good to see you again, Greg and Todd. Thanks for having me.

• 1:56Speaker 02

  Okay. All right. So you were, you were on probably right when, when Todd was host then, because I never forget a conversation with you. So I'd remember if it was, if it was you and I on that. But anyway, awesome, awesome to have you back then. We got a lot of good stuff to cover.

• 2:16Speaker 02

  You know, executive state association, I think most people would think that we'd start with, with PBM Reform at the state level, particularly because Arkansas is one of the absolute leaders in PBM Reform at the state level. And there's just sort of this pedigree of, of leading on PBM Reform. But we're going to be, I think, some, do something a little counterintuitive. And that is we're going to talk federal first, if that's okay with you.

• 2:43Speaker 03

  Sounds good.

• 2:44Speaker 02

  Great. Very good. So I think we're going to open it up and talk a little bit about TRICARE. And the reason is TRICARE has been hot, right? Lately, you know, Senator Warren and Chairman Tuberville held a hearing on the pharmacy program in TRICARE a couple, what, two, three weeks ago now? The weeks seem to click by. And that's something that you paid acute attention to. You're someone, you know, particularly, you know, you live in, in sort of the state world, but TRICARE is a program that you have paid, I would say, like razor close attention to. And I think there's a couple of reasons for that. Let's, let's kick off with you just kind of walking through why, in your opinion, TRICARE matters as much as it does.

• 3:27Speaker 03

  Yeah, thanks, Greg. So that hearing was on July 15th. There's been a couple, but the one on the 15th was specific to TRICARE and the U.S. Armed Services Senate Personnel Committee. Thank you for testifying in that particular hearing. I know a lot of national organizations and other state associations are, are dialed in on this issue. But going back to the early 2000s, just about every community pharmacy in our state participated in that network and they were proud to take care of America's finest, their military, their family members and retired military that are TRICARE beneficiaries.

• 4:07Speaker 03

  There's about 95,000 in this country, almost 100,000 lives covered by the program, largest employer program in the country.

• 4:16Speaker 02

  And point of pride, you said, right? And that's, that's always the impression I get are, you know, you know, independent pharmacists have, it has been a point of pride to care for TRICARE families.

• 4:28Speaker 03

  Yeah, Arkansas has a couple of air force bases, Army National Guard in our state, a lot of amazing human beings that protect our country, love our country, protect our country. We want to serve them, help them and their families access to care in our state. And in recent years, because of some things we're going to talk about in a minute, the majority of pharmacies in our state are no longer in network with TRICARE. And it primarily happened after 2022. I know you shared some of the data from Arkansas. You, you work with a lot of stores in our state, almost 100 pharmacies that your group that you work with, the APCI, that work with stores in lots of rural areas and underserved

• 5:13Speaker 03

  areas. But we went from nearly 700 plus pharmacies in our state participating to now less than 45% of the community pharmacies in our state. Walmart is not in network. They have 126 locations. There are 250 independent pharmacies that are no longer in network. And what's crazy, Greg, is Arkansas has about 500 cities in its state, you know, in the state, they're incorporated, about half of those, 250 have at least one pharmacy in them, all 75 counties.

• 5:53Speaker 03

  But for TRICARE beneficiaries, 56 or more than 25% do not participate in TRICARE. And seven counties and roughly 10% of the counties don't have a single pharmacy that participates in TRICARE. And there are areas.

• 6:09Speaker 02

  Stunning.

• 6:10Speaker 03

  Yes, it's real, it's, it's unbelievable. There are areas where there are 60, 80 mile areas where there is no access at all for, for patients in that program. And what's infuriating about it is the person who has a federal contract dictated in federal law, thanks to U.S. Congress in 2014, they get guaranteed mail order prescriptions. They get guaranteed fare dispensing fees to cover both their operations and their delivery. And yet that same entity who fills those prescriptions then is turned around and incentivized to run its competitor pharmacies, the local pharmacies in Arkansas, out of business and out of TRICARE.

• 6:55Speaker 03

  And that program, even though it operates differently than other programs, should not have somebody who's both a price taker and a price setter doing both functions. And when they do, bad things happen. They're incentivized to do the wrong thing.

• 7:11Speaker 02

  Yeah, I think, I think the way I had framed it maybe was it's almost like a poster child, you know, for why there shouldn't be vertical integration, why PBMs shouldn't own pharmacies. And so you, you just covered a lot of ground and I want to break it down a little bit for, for listeners. But before we get into the details and you, you've got some, you've got some great details. And I think my lead in here is you've spent a lot of time looking at TRICARE. You have, right? You know, considering you, you know, a lot of what you do is work on state healthcare policy, obviously try, you know, the problems in TRICARE is something that, that your members have felt acutely, that your members' patients, I think have felt acutely.

• 7:54Speaker 02

  But just why as a state executive, just what, what was the catalyst to you really diving in? Because I'm going to be honest, but there, I don't know a lot of state execs that have sort of done the work that you have regarding what is the impact to patients in the state? And how many pharmacies are in? How many pharmacies are out? And so A, why, why the interest? And B, I'd just be interested to hear sort of the process in terms of how, how you dug into, into that and sort of got a handle on just how vast the impact was.

• 8:28Speaker 03

  I think there's two reasons. One, when we do strategic planning with our board of directors to figure out what our profession needs to best serve patients, it became abundantly obvious that it didn't matter how many scope of practice bills we introduced, how much fare payment bills we introduced for both clinical services and for PBM services, and how many PBM Reform bills we passed. When you don't have access to the patient at all because your direct competitor is blocking access in order to steer patients to their own pharmacies in the program like TRICARE, it just became apparent that it was important.

• 9:08Speaker 03

  And then the second thing that I think acutely made it even more important was our state was the first to introduce legislation to stop conflicts of interest that are bad to drive up prices, to drive down access, to drive away competition. And that was of course, Act 624 that is now tied up in federal court in litigation.

• 9:33Speaker 03

  That brought it to the forefront as well because one of the key areas that's being litigated is TRICARE and how, whether or not it's preempted from state law for that program to have those mail order pharmacies that exclude and enacted an anti-competitive way to local pharmacies.

• 9:50Speaker 02

  Yes.

• 9:51Speaker 03

  So it became, you know, either way that case goes, it made it clear that we need to work on federal policies. And of course, the big three are Medicare, TRICARE, federal employees. I know managed care Medicaid and Medicaid.

• 10:05Speaker 02

  That's there, yeah, for sure.

• 10:06Speaker 03

  Yeah, that's there as well, but you can do a little bit more in the state with managed care Medicaid.

• 10:11Speaker 02

  I think that's an important point, right? States can touch Medicaid managed care, you know, they can touch Medicaid in certain ways, but have had a hard time, I'm not waving the white flag on this, right? But certainly have had a hard time reaching, you know, the Medicare market, TRICARE market, federal employee health benefits plan market, for sure. I'll tell you something that was, go ahead.

• 10:32Speaker 03

  Yeah, it also struck me because the Express Groups is arguing that state laws shouldn't apply to them, that they should be preempted from state regulations that deal with TRICARE, but at the same time, they're asking for the state to license and oversee them. So I don't know how you can be preempted, but at the same time, you want a license from an entity.

• 10:54Speaker 02

  Well, I think that's a great, yeah, I think that's a great point, something that's always fascinated me. Pick your federal program or even, even ERISA, right? Which obviously Arkansas led the nation in the, you know, PCMA v. Rutledge, all the way up to the, you know, really all the way up to the Supreme Court, right? And won. But I, I agree, right? I think there's, I, I just think there's so many interesting issues in terms of them trying to use some of these federal programs as a shield on the PBM side. But the reality is, when they're acting as a healthcare provider, when they're acting as a pharmacy, states enjoy broad discretion in licensing providers, right? There's a, there's a, there's a reason, and this is going to be ridiculous, but there's

• 11:36Speaker 02

  a reason why, you know, a, a nurse or a PA or a pharmacist can't do non-invasive heart surgery under their state license. And, you know, a, a PBM doesn't get to trump that by arguing preemption from state licensing laws and scope of practice laws. So I, I love the point you touched on. I don't think it gets touched on enough, right? To the extent that they want to act as a pharmacy and they own a pharmacy, it's a very different analysis from a preemption perspective than an insurer or PBM preemption analysis.

• 12:10Speaker 03

  And then how did I get the data? The data's on their website. You could, as a patient, as a taxpayer, you can go to the TRICARE website and look by zip code, every pharmacy in your state to see if that's in that work or not.

• 12:24Speaker 02

  And that's what you did. Wow. That, I'm sure it was painstaking, but I'll tell you what, it, like, again, you, you've got a better handle in your state than anyone I've talked to in terms of what was, you know, what's the impact of sort of these practices and these policies at a state level, driving out of TRICARE, tremendous. And so that's how you did it. Something else I thought was interesting is, in some of the complaints, you know, particularly ESI's complaint in the state of Arkansas, boy, you know, they, they divulged some, some fascinating information in trying to kind of wield TRICARE as a preemptive, I don't know if you'd say sword or shield, right? But in, in trying to argue preemption, I mean, one of the things that stunned me, I'm

• 13:08Speaker 02

  not sure I'm going to get this exactly right, but I think if you do the math based on what they said, something like 50% of the mail order prescriptions in Arkansas come from the TRICARE program. Stunning, right? It shows you just how massive of a program TRICARE is for ESI.

• 13:27Speaker 03

  Yeah, it is. And I would say too, we have a US senator who serves on armed services.

• 13:35Speaker 02

  You do.

• 13:36Speaker 03

  So, you know, when you're in a state where you have a, one senator's on US Armed Services and the other senator, John Bozeman, so Cotton, Armed Services, and then Senator John Bozeman's on Veterans Affairs. So both of our senators, US senators, serve in capacities that have an interest in what happens with our military and their families. Senator Cotton's healthcare liaison, Riley Larson, took a great interest in this. Earlier this year in March, he introduced a bill, a companion bill to a House bill, the RX Access Act, that Senate Bill 4106, I believe, is the number that would fix reimbursement. Yeah, I mean, there's, it's, it's a good start.

• 14:20Speaker 03

  That bill probably by itself is not going to move by itself, but it could move as part of a package. And one of the components of that bill, the mandatory audit, of course, has been introduced in collaboration with Senator Warren in Massachusetts, across the aisle, as well as in the House and passed the House. And we hope that that moves later this year. But one thing that struck me in the hearing where you testified, Greg, and I'm going to talk about your testimony for a minute, but one of the reasons why, when you go back to 2003, when Express Groups first got the contract, so they've had it for 23 years, in 2014, the federal government wrote into federal code.

• 15:01Speaker 02

  Beautiful. I was going to ask you this, yeah.

• 15:03Speaker 03

  Guaranteed protection and guaranteed filling of the prescriptions by a PBM-owned pharmacy over local pharmacies for brand name mail order farm, or prescriptions.

• 15:14Speaker 02

  Yeah, I think it's right, brand name maintenance meds.

• 15:17Speaker 03

  Yeah, brand name maintenance meds. And they've allowed them, through congressional action, given data that's not been ever validated by an independent audit, that it's less expensive to do it this way with their program. And in the hearing, there were two or three things where Admiral Smith testified and you were testifying, and the pharmacist from Clovis, New Mexico, was testifying, the pharmacy owner, as well as the Express Groups president. And in that discussion, I think there were two big issues to me, well, really three. One, should your competitor be setting the prices of its competition?

• 15:59Speaker 02

  Right.

• 16:00Speaker 03

  In terms of dispensing fee and access? I think that's a big no, but that's one of the big themes. Number two, is Express Groups paid more, paid higher dispensing fees and higher admin fees and higher delivery fee fees than local small business pharmacies in Arkansas? And then are they really cheaper? You know, one of the things in 2008, Congress passed a bill that guaranteed that on brand name drugs, that prescriptions filled at retail would be eligible for the federal supples schedule rate and post adjudication rebates.

• 16:36Speaker 02

  Which is, which is a huge deal, right? It's a huge deal and it's something that you don't hear DHA talking a whole lot about.

• 16:43Speaker 03

  No, matter of fact, Admiral Smith didn't mention it at all in the hearing, at all. He didn't mention it. You brought it up. He didn't acknowledge it, didn't comment on it.

• 16:51Speaker 02

  Didn't deny it though, did he?

• 16:53Speaker 03

  And certainly, he didn't deny it, but there's never been an audit to look and see what that post adjudication price is. And then, and on top of that, you and Senator Warren provided proof from their own data that mail order generic prescriptions are more expensive at the mail order pharmacy. So if they're more, yeah, if they're more expensive, then why are more and more generic prescriptions being forced and sent and incentivized through copay advantages to mail order pharmacy?

• 17:20Speaker 02

  And it's such a, you know, TRICARE is unique, right? Like for, like, there's no question about it. But, you know, if you, if you dig into DHA's own reports, you know, it tells a very different story from what's communicated to TRICARE families, TRICARE beneficiaries, you know, which is always mail order's cheaper, mail order's cheaper, mail order's cheaper. And indeed, what's so unique about the program is there's literally copay tiers built into the federal code that appear almost punitive for TRICARE families that want to use a retail pharmacy, right? It's, I think it's like for a 30-day generic, it's like $16 in 2026. For a 90-day mail order, it's something like $14. And they communicate this everywhere to TRICARE families and TRICARE beneficiaries,

• 18:04Speaker 02

  DHA's, as well as the PBM. And, and so, you know, if you're, if you're looking at it, it's like, oh my God, it's, it costs me 300% more in, in out of pocket to get 90 days filled at retail. But the, but the reality is, in practice, they use a lesser of logic at the retail pharmacies and they reimburse the mail order at the maximum. And so, in fact, retail, despite what it looks like in the code with these copay tiers, the reality is. Express scripts mail order on generics can be massively more expensive for TRICARE families than retail pharmacies. And I think DHA's own reporting also reflects that in the aggregate and on average in the

• 18:48Speaker 02

  generic market. And then as a result, and I don't recall the exact percentages, but what we saw is leading into sort of this 2022 decision to cull the network by between 13,000 and 15,000 pharmacies, TRICARE families were, I would go so far as to say flocking to retail pharmacies, and mail order was losing market share. And so what happens? There's this decision under the auspices of cost savings, right, to cull this retail network, which I would argue, or at least seemingly disproportionately seem to impact independent pharmacy access to these networks.

• 19:24Speaker 03

  The other thing that motivated me, you said, why does a state exec care so much about this? We had state legislators during the session testifying, if you want to see hundreds of pharmacies close, then let's do nothing and act like TRICARE acts. Basically, the worst employer, the worst pharmacy program, the worst access in the entire country is TRICARE. So TRICARE is the model of how not to do it for every other program, whether you're talking about state employees, two and four-year public universities, municipal league, city and county employees, Medicaid managed care, Medicaid, on and on, for all the state regulated

• 20:09Speaker 03

  plans that are state-funded, plus employer plans, ERISA self-funded, bigger companies. If we don't do anything, the testimony was basically, this is how it's going to end up. Because the PBM in the TRICARE program has completely, with Congress's help, rigged it in a way that's heads they win and everybody else loses, tail everyone loses.

• 20:35Speaker 02

  Yeah, so well put, right? From my perspective, there's one winner here, and it's the contracted PBM. But, boy, you've mentioned it, I think, in passing at least two or three times here, right? But for context, this stuff was passed by Congress, right? Like, we have this uneven playing field, where on paper, it's cost prohibitive to use retail pharmacies for certain medications, and then for other medications, retail pharmacies are literally blocked out. They can't fill those prescriptions, you know, even if they wanted to. And this is, it's codified.

• 21:15Speaker 03

  Yeah. And it's, you know, if you're comparing to federal programs in our state, if only 45% of the pharmacies are in network, which is the truth, only 45% are in, at the same time, nearly 100% are in Medicaid. So, patients with Medicaid, just as important as patients that are military, military families in terms of access and care, Medicaid families have double the access compared to TRICARE.

• 21:47Speaker 02

  That's stunning. I mean, that's stunning, when you put it in that perspective, right? Medicaid beneficiaries have almost doubled the access to retail pharmacies in Arkansas. Then TRICARE beneficiaries.

• 22:00Speaker 03

  And you might say, and I know most of our listeners know, but that includes compounding, same-day access, antibiotics, antivirals, pain medicines, compounding, long-term care, assisted living support, all the things that you can't get through mail order, I mean, they're lost to these families. And you heard my statistic earlier, in 56 cities in our state, they have a pharmacy, but they don't participate in TRICARE. And it's a real problem.

• 22:30Speaker 02

  Wow, it is. You know, something, I don't want to get lost, and I don't know that I put a fine enough point on it in the hearing, but, you know, DHA likes to talk about the cost driver being brands. But when we saw sort of this exodus of between 12,000 to 15,000 retail pharmacies in late 2022, early 2023, under the auspices of cost savings, I think what gets lost is, you know, that DHA's own data reflects that retail pharmacies dispense as high as, I think, 88% of the drugs they dispense are generics. And one of the reasons is, federal code blocks their ability to dispense brand name maintenance medications. And so to try to say, hey, we're going to cull this retail network for cost savings,

• 23:15Speaker 02

  brands are a big driver, and then the reality is that retail pharmacies are dispensing 88% generics, it doesn't reconcile, does it? Right? It doesn't, you know, this notion that somehow that was going to lead to cost savings, it just doesn't reconcile with their own data, from my perspective. So, I want to make sure we have time to talk about, you know, your just amazing work, and your association's amazing work in states. But just to stay on this point, so, let's say 2022, late 2022, early 2023, we sort of see this exodus, you know, then you pass, you know, the Vertical Integration Act, was Act 624?

• 23:57Speaker 03

  Yes.

• 23:58Speaker 02

  Yeah, so you pass Act 624, and that was, what, 2025? And so, really, it sounds like you're, these last few years, you've really honed in on what's going on in TRICARE for sort of these twin reasons, which is the exodus of pharmacies, and then on top of that, you know, what's transpired in connection with Act 624. Arkansas has fast become, you know, a central player in this, right? You mentioned Senator Cotton, you know, introducing legislation. I think your policy expertise has certainly helped shape and create sort of this understanding that, hey, there needs to be an audit.

• 24:39Speaker 02

  You know, you've played so significantly at the state level for so long, and I think somehow, sometimes people think federal can be incredibly daunting, and certainly, things move slower federally. But, I mean, man, like, you've, you know, you have had a hand in shaping TRICARE policy in really a very, very short time, and it's just a fraction of what you spend your time doing. Is that, any thoughts on that?

• 25:07Speaker 03

  I think that's fair, and I would say that PUT, and NCPA, and APCI, American pharmacies, there are a lot of groups nationally that help provide information.

• 25:19Speaker 02

  No, for sure.

• 25:20Speaker 03

  Yeah, like, you and I have had a lot of conversations about this, and TRICARE, I didn't understand. I mean, I'm learning, just in the last six months, what the problems are, and why, and how it's evolved that way, but it's taken some time to really dig in and understand it. Now that I understand it, I feel like we can, at least in our state, advocate for change, and we've got to get these federal programs changed. I mean, fixing things at the state level is literally only half the battle. And Congress, many times, is made up of former state legislators who listen and look back to what their state has done.

• 25:56Speaker 02

  Absolutely.

• 25:57Speaker 03

  So I think they go hand in hand in working with our federal partners.

• 26:00Speaker 02

  Yeah, well, I'll tell you, one thing I was excited about, and this is a little bit of a changed subject, but I think related, was the reintroduction of Pharmacist Fight Back Act in December. And, you know, there was a press conference, and, you know, two bills, 6609, 6610, 6610, very recently marked up by House Oversight, which we're really excited about. But to see, you know, just sort of, just leaders on healthcare policy at the state level, particularly pharmacy policy at the state level, show up, you know, in support of that fight, I thought was really cool, right? And there were, you know, you were there, you know, Randall out of Louisiana, Ben out

• 26:43Speaker 02

  of Kentucky, who we had on, just, I think it was last week, we released a podcast with Ben. Obviously, Kentucky does great work, but I thought that was, I think it's cool to see folks sort of with that track record and that pedigree, starting to sort of pay atten, you know, not starting to, but, you know, paying attention to what is happening at the federal level, and making their mark. To your point, right? Like, great work's obviously been done on TRICARE. I think the PUT, you know, audit TRICARE program has really garnered a lot of attention. NCPA has been, you know, critical, I think, also, in sort of this process of securing it. But nonetheless, like, I think you're being modest, right? I think you've helped shape where folks are looking and the rocks they're looking under,

• 27:28Speaker 02

  and helped make, really draw some attention to TRICARE and that program. So, I think we've talked a good bit about TRICARE.

• 27:39Speaker 02

  We could do probably like a five-episode special on the work that you have done at the state level. And I want to talk about some of the work you've done at the state level, but you know, you mentioned sort of champions flowing up, right? And legislators and leaders at the state level and federal folks looking to them or evolving and then becoming. But, boy, Arkansas has some, Arkansas has some pharmacy champions and some champions for patient access to care, doesn't it?

• 28:09Speaker 03

  Yeah, that's the, you just hit the nail on the head. The patient access to care is what all of this is about. You know, fair, better pricing, fair competition, access, and ultimately, patient outcomes. We had, you know, lots of patients and patient advocates testify this last session, more so than ever before. And one of the things that's really changed a lot of hearts and minds, just learning and learning from others, is we've gotten the input and the partnership from our oncology partners. So our oncologists, the pharmacists who work with a lot of chemotherapy drugs and oncology drugs, as well as the physicians,

• 28:53Speaker 03

  APRNs and PAs that prescribe them. One of the most staggering statistics, and you think about this, when you go into the emergency room or hospital and you have sepsis, you expect your drugs to treat your infection to be available right then and there, because every minute you delay increases your likelihood of increased morbidity and mortality. Well, chemotherapy is the same thing. For every four-week delay in access to a chemo drug, your mortality goes up by 10% on average. So every day literally increases mortality

• 29:32Speaker 03

  risk. And that's been central to a lot of the discussion around whether it is narrow networks of drugs that are limited distribution to primarily mail-order PBM pharmacies, whether it's the anti-competitive acts of owning a pharmacy, as well as setting network rates and prices and access to pharmacy from an anti-competition perspective, fair and reasonable reimbursement methodologies, better enforcement of our existing laws, and also needed litigation in the market. We've, we've been trying to either pass legislation, better enforce

• 30:12Speaker 03

  in all of those areas. And I know I've been on before with some other groups, and I've said, oh, it's an acronym. Arkansas is the natural state. That's L for litigation, E for enforcement, A for stopping anti-competitive acts, and F for fair and reasonable payment models. And I was at the McKesson Ideas Share Meeting, and somebody came up to me and goes, you know, that spells FLEA, L-F-L-E-A. That's what we're trying to kill, or the pesky little fleas that are destroying, yeah, patient access. So I may have to change the acronym order there with fair and reasonable reimbursement being number one, but...

• 30:49Speaker 02

  Switch it, switch it around. Well, you know, I'm glad you mentioned oncology. You know, we talk so much about vertical integration just in this industry, and, you know, its impact, and obviously, steering is, is front and center. But sometimes I do think what gets lost is, central to kind of the steering strategy, by the big PBMs are targeting the sickest patients that there are, right? They're targeting them, they're restricting their access to their oncologist, to their pharmacist, and, you know, they're steering into those channels. And then on top of that, what we see so often is not only are they, you know, disrupting care, interrupting care, delaying care, but then they're marking these medications

• 31:31Speaker 02

  up, hundreds to thousands and thousands of percent on the sickest patients that there are, right? Literally, patients that are fighting for their lives, patients where, where time matters, money matters. And, you know, we're seeing the required mail order, we're seeing the delays, but we're also seeing just, just massive price manipulation as well.

• 31:54Speaker 03

  Yeah, it wasn't just the FTC reports. We've seen the insurance department in West Virginia and Tennessee found that same thing. Mississippi Board of Pharmacy, if you've read the news lately, there are certain PBMs in Arkansas, Alabama, and Florida who are just refusing to cooperate with audits. It's not just the FTC, it's also now at the state level, where they're just shifting, shaping, refusing to cooperate, which gets back to the, what should the penalties be in the enforcement side of it? In response to that, we got work to do.

• 32:29Speaker 02

  But we got a lot of work to do, right? Because one of the things we see across the country is even when they lose, it can be a good day in the office for PBMs, right? If they get a, you know, if, if a big PBM gets whacked with a fine for a practice that they made hundreds of million dollars on, that's still not a bad day in the office for them, is it? Maybe not even necessarily a deterrent.

• 32:50Speaker 03

  I agree.

• 32:51Speaker 02

  Okay, so, so this is a digression, but one thing I thought was cool, you mentioned patients that came to testify, and, you know, patient advocates. And I thought, one thing, I'd love to give a shout out, A, to you all for recognizing her, and also to her. But at your association meeting, I want to say it was early June, you guys recognized somebody who I admire greatly, which is Loretta Bosing. If you want to give a shout out to her and talk a little bit about sort of how you, how you recognized her, I thought that was a really cool moment.

• 33:21Speaker 03

  Yeah, she's awesome. She and her husband came, and our board recognized her with the Patient Advocate of the Year Award. It's only the second time we've given that award out. And actually, the first time it was given, it was given to Governor Sarah Huckabee Sanders, in her efforts to highlight patient access in the New York Times and sign legislation and kind of put it to a national level. But Loretta has been a good partner, not just in Arkansas, but across the entire country. She's very brave for doing so. Yeah, it's not, you know, when you talk about your own family or your own access issues, of course, you're fearful that your benefits will be cut off, or that your employer will be mad

• 34:05Speaker 03

  at you. And it takes a lot of time and sacrifice to kind of put yourself out there in such a public way. And she's incredible. She and her family for, for being brave and for speaking up and fighting for so many, you know, there was a, in the discussions in the hallways of the Capitol, one of our legislators, in response to hearing her testimony, shared with me that he had just had a patient come in that had an autoimmune disorder of the eye called uveitis, and needed a specialty drug, and got the prior authorization approved. And then it was forced, of course, to a single pharmacy through the mail. And that patient never got it filled, even though it was approved, for whatever reason. You know, in the phone

• 34:50Speaker 03

  tree, if somebody can't talk or figure out how to answer the phone and coordinate with the patient, which gets back to, this is not just a commodity, it's an actual delivery of patient care, which includes a relationship and coordination of care and follow-through to ensure that diseases that are life-threatening are treated. And, you know, he heard Loretta's story and shared with us that this particular patient had gone without this medicine for several weeks, and had permanently lost 75% of her vision, permanently.

• 35:25Speaker 02

  Yeah, I mean, that power of a personal story, right? Like, I do think drug pricing and sort of some of these PBM practices, it can be esoteric to people, right? You can be talking about these giant aggregate numbers, hundreds of millions of dollars, billions of dollars, or, you know, markup Silver Nadac, you know, thousands of percent. And it's easy to get caught up in sort of these esoteric concepts. But I think, you know, something Loretta always does well, and sort of the experience you just shared, right, is like when a patient tells the story of how PBM practices have impacted their care or their loved one's care, it, it brings it home, right? I mean, I've, I've heard patients testify

• 36:07Speaker 02

  in Georgia and other states, and, you know, boy, you could have heard a pin drop at the end, right? Like, it can, you know, that personal story, I think, can, can suck the oxygen out of a room sometimes.

• 36:19Speaker 03

  I agree.

• 36:21Speaker 02

  And it takes, you know, for patients, boy, it takes, it takes guts to do it, right? I mean, they're not, they're not professional speakers. And I've seen Loretta, right, show up to states where she has no, like, contacts in rooms with, you know, lines of people lined up, professionals on the other side, and get up and tell her family's story. And, you know, pretty, I think that takes a lot of guts. I thought it was really cool that, that you all recognized her. So I thought that was neat. Now, you mentioned, you mentioned Governor Sanders. She's turned out, I would, I would argue, to be one of the most prominent sort of like national, I don't want to say spokespeople, right, but really an advocate,

• 37:03Speaker 02

  one of the, one of the strongest and most prominent advocates for, for PBM reform. Is that, I don't think that's hyperbolic to say. Would you agree?

• 37:11Speaker 03

  No, I agree. She, you know, she's a cancer survivor herself. I don't know how many of you know that, but she's herself, she's a patient. Yeah, she's a patient, she's a survivor. And I think she really gets it. I mean, she understands, she's like the rest of us, fighting this broken system and trying to find good reforms that put the patient first, and put patients over profits in our policy reforms. And we're proud of her for doing that in our state, and also elevating the conversation across the country.

• 37:47Speaker 02

  Yeah, it's cool. And you know, every now and then, you know, she'll push something out on social media. I want to say, was it last week? I think she pushed, she pushed

• 37:55Speaker 03

  She did.

• 37:56Speaker 02

  Something out. Yeah. And, and you just, you know, just powerful message and it catches on when she does it. It's amazing.

• 38:02Speaker 03

  Yeah, the video started out with PBMs. You can't explain it in one sentence.

• 38:07Speaker 02

  Yeah.

• 38:08Speaker 03

  There's a reason.

• 38:08Speaker 02

  Yeah, that's right. Man, that ain't, that ain't, that ain't no lie, is it? Arkansas has a lot of other champions too, as well as some pharmacists in, you know, in, in the state capital. I would argue you guys have not, not only a pedigree of winning, but a pedigree of cultivating, again, champions for patient access to care, champions for PBM reform. Is there, is there a secret sauce? I think so often when you're in other states, you look at a state like Arkansas and it's like, oh my God, you know, they struck lightning and something happened over, proverbially overnight. But, but there's been, I'm going to suspect, I don't want to take words out here, I'm going to suspect that there's, there's

• 38:51Speaker 02

  a lot of work over a long period of time that builds upon previous work. But I'd love to hear, hear your thoughts.

• 38:58Speaker 03

  I think the secret sauce is no one cares more about this issue and how it affects our communities and our patients and those stories that I just shared than the pharmacists of the United States of America. And what you saw recently in Alabama, in Kansas, and Montana, and Kentucky, and Tennessee, and Oklahoma, and others, I'm going to leave somebody out, New Mexico, West Virginia, there's so many good examples.

• 39:26Speaker 02

  What about Louisiana, John?

• 39:27Speaker 03

  Louisiana is a huge one. I mean, Louisiana is a huge story. But thinking about, you know, Kansas shutting their stores down for a day to come up there firsthand in person and explain how this is destroying not only the price of drugs, but access and local, the ability to provide that locally is, is so effective. And that's one of the things Arkansas has done. We've been that same thing.

• 39:56Speaker 02

  But you didn't just start, did you?

• 39:56Speaker 03

  No, it's definitely an ongoing battle and it's, and it's, we're learning from some things that other states have passed us on, on the fair and reasonable reimbursement standards. We have a rule 128 and a cost of dispense that's being implemented in certain plans in our state, but it could be better. And we could, we could learn from states like Tennessee and Kentucky and others to see how we can better improve that implementation in our state. You know, Oklahoma has some, whenever they, the AG's office fines for non-compliance, some of those dollars go back to the affected pharmacy. That's so critical because of the

• 40:37Speaker 03

  time and staffing and harm that was done to file the complaint to try to resolve it. We, our state added a 12% penalty per month back to the pharmacy for underpayments, for under reimbursements, for below invoice cost, as well as below a cost of dispense reimbursement, and also prompt pay, which you and I've talked about, that speeds up in the commercial market to match what happens in Medicaid and Medicare, which, which ironically has been fixed in some of our federal programs, but still lags behind in our state PBM laws. We finally

• 41:17Speaker 03

  caught up on that with a penalty of 12% interest payments per month back to affected pharmacies.

• 41:24Speaker 02

  Yeah. So, you know, something that I've always admired about, about Arkansas and your work is obviously, you know, you've got a robust legislative advocacy platform. You know, obviously the state has not been afraid to stand its ground and litigate. And you've not been afraid, you know, to advocate for, you know, new first of its kind legislation more than once. But, you know, some of the reimbursement work that Arkansas has done hasn't necessarily been exclusively legislative, right? There's been a lot of regulatory work in Arkansas on that front as well. Am I right in that? And I think that's, that's kind of unique. I think it's an important point to draw out, right? Like you don't look for,

• 42:07Speaker 02

  you know, you, you don't look in one arena, right? I mean, you're, you're looking for opportunities wherever those opportunities may be.

• 42:12Speaker 03

  We are. And I would say too, this is something I want to make sure and give credit where credit's due. We also have, we talked about time and talent, you're talking about strategy. But the final piece of that is money. State associations run off shoestring budgets. They need resources. The states who have resources into their state advocacy efforts and state associations usually are the, the venue for that, not always, but usually I would argue they should be because they're the longest lasting. Our association's been here since 1881.

• 42:50Speaker 02

  Wow.

• 42:50Speaker 03

  Just for perspective and.

• 42:52Speaker 02

  Now, you, you yourself have not been there since 1881 though, right?

• 42:56Speaker 03

  Not, not quite. Close, but not quite. But, but we've had, you know, our independent pharmacists, some of our industry partners, wholesalers, particularly Morrison Dixon, Smith Drug, who I know is in transition right now, McKesson Amplify, you know, there's the Cardinal One Voice. There's a lot of good financial support out there to help us in these efforts. And it's impossible to do it without dollars. So you, you, you know, good advocacy effort, you think about PR and media and all that stuff. But the reality is you have to have human beings to help kind of lead the efforts.

• 43:39Speaker 02

  Yeah, that's right. Yeah, I agree. And, and that, that does take money, right? Whether it's money directly to the association or, or to PACs. You know, one thing I'll say, and look, obviously not all states are created equal in terms of number of pharmacies or robustness of associations. But having, you know, professionals on the ground to understand the political process as well, whether that be, you know, executive directors or contract lobbyists. I'll tell you this, I was, you know, I've, I've had the honor and pleasure of, of visiting Arkansas and watching you all kind of do what you do in the thick of it. And, and boy, I, I, I obviously, you know, incredibly impressed by you, but super impressed by Deborah as well.

• 44:19Speaker 03

  Yeah, she's awesome, man. We're fortunate to have her.

• 44:23Speaker 02

  Having the right, you know, the right team who, you know, who understand the politics and understand the policy. And, you know, it's, it's, I always say this, right? I'm a broken record on it. But I, I think, you know, outside looking in, if you're a pharmacist in certain states, you know, if you're not super involved in the political process, I think it becomes easy to think that it's, that it's not hard to pass a bill and what all goes into it, right? And the reality is, it's really hard to pass a bill about anything in any state. And then when you're trying to pass a bill against well-funded, organized opposition with, you know, almost limitless pockets, it becomes that much harder. And the difference between like victory and, and defeat can be, can be so thin, right?

• 45:08Speaker 02

  Again, it's easy to look at like Arkansas in 2025 from the outside looking in and say, man, that, that was, that was easy. But I think, you know, again, I was, I was there for one or two days. I think I can vouch for, you guys worked pretty dang hard and opposition was flooding a lot of money in, into that state to, to keep the status quo. I don't think you would say it felt easy when you were doing it, would you?

• 45:32Speaker 03

  No, it certainly did not. It's not. It's worth it though. Not to be a broken record here, but the, the patient access and the patient care and being able to recruit future workforce to want to be pharmacists, that is a real issue, man. Like recruiting the, the brightest and the most talent into our profession to, to continue to provide these services in our local communities is not going to be easy unless we fix these issues. So that is an also, that is also a driving force for the future.

• 46:09Speaker 02

  Yeah, that's, and that, that doesn't get talked about a lot. So, yeah, so, so glad, so glad you brought that up. And, and I, I think even when you're talking about PBM reform, right? Like there are, you'll know more about this than me, but I mean, there, there are real issues in terms of recruiting students for pharmacy schools now for a number of reasons. But I would argue sort of industry conditions and reimbursements and patient access all fold into that.

• 46:36Speaker 03

  Yeah. And I will say, I'm going to bring it back to TRICARE again, but we've got the big, beautiful bill and there's rural health transformation dollars and there are going to be a lot of states try to address pharmacists as prescribers, pharmacists as being able to order labs, pharmacists being able to diagnose for simple conditions, similar to the way pharmacists do in Canada. I think Alaska was the most recent state to have success at that in the, on the clinical side, which I think is exciting, you know, for delivering care. And the worst program for that vision is TRICARE. Because you can't even access

• 47:17Speaker 03

  the patient. So you got Congress on one hand saying, we need to invest in Dr. Oz. Pharmacists are awesome. We need, yeah.

• 47:25Speaker 02

  I'm so glad you said that. And I, one of the things, you know, anytime you're like up at a table, you know, there's always things you go back and like, oh man, I wish I would have said that. But I, you know, there was a question of, right? Like what can pharmacists offer and provide to improve outcomes? Something like that. I'm paraphrasing. And the, the biggest thing I regretted is like pharmacists can't if they're not in the network, right? And you just articulated that perfectly.

• 47:51Speaker 03

  What upset me the most about Dr. Smith's testimony, Admiral Smith, the DHA Deputy Director. Somebody, I think Senator Blumenthal, was it Blumenthal, asked him, Dr. Smith, you know, kind of bigger picture in the country, what is the one thing that you think needs to change to improve healthcare in America? So like, he's not getting him in the weeds. And he could have answered anything. He could have said, costs are too high on brand name drugs, we don't have a good research pipeline, whatever, PBMs, insurance, could have answered anything. And his answer was, we can't recruit and retain healthcare professionals into

• 48:36Speaker 02

  That's right.

• 48:37Speaker 03

  the nation or into our program here at the US Department of Defense. And I'm sitting there thinking, Dr. Smith, how can you say that's the worst challenge in all of American healthcare? And at the same time, you are adopting and implementing a completely broken model that destroys the ability to recruit and retain healthcare professionals in rural America? I mean, he, like, that's the biggest contradict, you know, contradict, yeah.

• 49:04Speaker 02

  Yeah.

• 49:05Speaker 03

  Contradictive stuff.

• 49:06Speaker 02

  Well said. Man. Well, look, I think that's probably a pretty, pretty good note to end on. I'm gonna, I want to ask you two questions and then, and then we'll wrap this up. You've been really generous with your time. One is, you know, if you're a pharmacist in a state that maybe doesn't have sort of this track record of, of reform that Arkansas has, um, and you know, you're, you're hungry to see that type of reform, to see that type of change, you know, what, what, what advice would you give pharmacists who, who want to see strides taken similar to Arkansas, Kentucky's, Louisiana's, Tennessee's?

• 49:40Speaker 03

  I think most of the state associations, if not every single one, if they had an investment of time, talent, and finances from the pharmacist in their state, anything is possible.

• 49:54Speaker 02

  They could get it done.

• 49:55Speaker 03

  I mean, I really do. I think any state in the country can get meaningful reforms done.

• 50:00Speaker 02

  I think pharmacy has proved that, right? I mean, when you think about it, right? I mean, there, there are states that, that have turned it around pretty quickly.

• 50:07Speaker 03

  I agree. Time, talent, finances. Get involved.

• 50:12Speaker 02

  Very good. Okay. Last question, and I don't know if this will be an easy one, but you've worked on, you've worked on some big bills, man, right? Like, you've, you've passed some meaningful stuff. I'm a big believer in a rising tide lifts all ships. I think the work of Arkansas has lifted the ship of, of, you know, patient access, PBM reform, community pharmacy, all over the country. Is there, is there, can you point to one thing, one bill that you've worked on that you're, or one fight that you fought that you're most proud of on behalf of yourself and, and, and your, you know, your association?

• 50:47Speaker 03

  You know, I, there's a lot that I could point to where we know what the result is and what meaningful thing has occurred as a result of it, like fair and reasonable reimbursement and prompt pay and the clinical things that we've passed where pharmacists can prescribe vaccines and contraception, strep throat, flu, test and treat, all those things. Those are all important, but I think when it's all said and done, addressing the root cause of the problems, the vertical integration, anti-competitive acts that, that break the market, uh, you know, when 70% of the independent pharmacies in Arkansas are not participating

• 51:29Speaker 03

  in TRICARE because there's a vertical integrated company that steers everybody to themselves on the federal government's dime in TRICARE, and, and when 70% of every specialty drug is filled, uh, at three pharmacies owned by three PBMs. Act 624, which I know has, the final litigation has not ended, but it raises the conversation nationally. It impacts what the Federal Trade Commission does, it impacts what Congress is doing. I think that bill and the work we've done on that will be the thing that, and when the dust settles, when you look back 20 years from now, will be the most important work

• 52:09Speaker 03

  we've done to try to address, uh, access to care, fairness, and to protect patients from, that have cancer in our country.

• 52:17Speaker 02

  Well said. Well said. I'll, I'll say this, crazy that winning in the US Supreme Court is, is, isn't top of your list, right? It just shows you how much unbelievable work has been done in Arkansas. And I'd also say, I think the work that you've done, you know, with Act 624, has inspired a movement outside of just pharmacy, right? Vertical integration between insurers and PBMs, or you look at the work of like American Economic Liberties and, and the breakup, Big Medicine Act, and so, at the federal level. I, I think, you know, there's, you've done a lot to be proud of, but I absolutely, I get it. That's something, I think when you look back 10, 15 years, you know, the work that was done in Arkansas will have opened the door for really, really meaningful change. So just, John, you know, welcome back anytime. You're a good friend.

• 53:01Speaker 02

  Can't tell you how much I admire the work you do, and thank you so much for being on.

• 53:05Speaker 03

  Thanks, Gary. Appreciate it.