PBM Member Message

Alabama Community Pharmacy Relief Act

Effective October 1, 2025, the Alabama Community Pharmacy Relief Act will change the way Pharmacy Benefit Managers (PBMs) reimburse community pharmacies in Alabama. The Act was intended to provide financial stability to community pharmacies in Alabama by increasing reimbursement to the Alabama Medicaid rate. The Alabama Medicaid rate includes the average cost of the drug itself plus a standard amount for the community pharmacist’s time and effort to fill the drug (a dispensing fee).

We appreciate the value that our community pharmacies provide our customers and are fully committed to complying with the new law. We also know that changes sometimes can be frustrating and may create confusion, so we want to be sure that you have information related to the Alabama Community Pharmacy Relief Act. As always, we are also available to answer any questions that arise and to make sure you understand your benefits.

What is changing?

  • On October 1, 2025, customers may see changes to the amount they owe when picking up prescriptions at a community pharmacy in Alabama.

What is not changing?

  • Copay amounts. Customers will not pay more than the designated copay for their prescriptions. These set copays are a standard part of each customer’s health benefit plan and are available by calling the customer service number on the back of their member ID card.
  • The way copay amounts and out-of-pocket costs are applied. Health plans have always required customers to pay the lesser amount of the cost of the drug (which includes the dispensing fee) or the designated copay.
  • Medicare Plans, including Blue Advantage and Blue Rx, are not impacted by the new law.

Here are some examples that may help you to understand how and when the new law may change the amount that must be paid out-of-pocket for prescriptions:

Examples when member costs will increase:

Current state

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$3.00 $0.05 $3.05 $15.00 $3.05 $0.00

Mandatory reimbursement rate for Alabama independent pharmacies required by the Alabama Community Pharmacy Relief Act starting 10/1/2025

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$3.00 $10.64 $13.64 $15.00 $13.64 $0.00

In this example, the member will pay more because the Allowed Amount has increased as required by the Act ($13.64) but the Allowed Amount is less than the member’s applicable cost-share ($15.00); however, the Plan Sponsor’s cost will remain unchanged.

Current state

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$3.00 $0.05 $3.05 $10.00 $3.05 $0.00

Mandatory reimbursement rate for Alabama independent pharmacies required by the Alabama Community Pharmacy Relief Act starting 10/1/2025

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$3.00 $10.64 $13.64 $10.00 $10.00 $3.64

In this example, the member will pay more because the Allowed Amount has increased as required by the Act ($13.64) so the member is required to pay their applicable cost-share ($10.00). The Plan Sponsor’s cost will also increase.

Example when member costs will remain unchanged:

Current state

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$500.00 $0.05 $500.05 $40.00 $40.00 $460.05

Mandatory reimbursement rate for Alabama independent pharmacies required by the Alabama Community Pharmacy Relief Act starting 10/1/2025

Ingredient Cost Dispensing Fee Allowed Amount Copay Tier Member Responsibility Plan Sponsor Responsibility
$500.00 $10.64 $510.64 $40.00 $40.00 $470.64

In this example, the member’s out-of-pocket responsibility will remain the same because the member’s applicable cost-share ($40.00) continues to be less than the Allowed Amount ($510.64); however, the Plan Sponsor’s cost will increase.