Pharmacies play a vital role in the healthcare ecosystem, ensuring patients can access the medications they need to maintain their health and well-being. However, pharmacies have been facing significant challenges in recent years, one of which is the impact of direct and indirect remuneration (DIR) fees. These fees, assessed by pharmacy benefit managers (PBMs), have been a source of frustration and financial burden for pharmacies across the United States. This blog post will explore the upcoming DIR fee changes and discuss what pharmacies need to know.

DIR Fees updated

Understanding DIR Fees

Direct and indirect remuneration fees are retroactive fees charged by PBMs to pharmacies after the point of sale. These fees are often based on performance metrics such as medication adherence and generic dispensing rates, and they can substantially impact a pharmacy's bottom line. The problem with DIR fees lies in their unpredictability and lack of transparency, making it difficult for pharmacies to plan their finances effectively.

The Impact on Pharmacies

DIR fees have been a significant concern for pharmacies of all sizes, but they have particularly affected independent and community pharmacies. These fees can eat into pharmacies' reimbursements, making it challenging to cover operational costs and invest in patient care services. Moreover, the retroactive nature of DIR fees makes it difficult for pharmacies to forecast their cash flow accurately, creating financial instability and hindering their ability to grow and thrive.

Upcoming Changes

Recognizing the detrimental impact of DIR fees on pharmacies, there have been efforts to address this issue at both the state and federal levels. The Centers for Medicare and Medicaid Services (CMS) proposed new rules in 2021 to reform DIR fees and improve transparency. These changes aim to eliminate retroactive fees and require PBMs to assess these fees at the point of sale. Additionally, the proposed rule seeks to establish a standard methodology for calculating DIR fees, providing pharmacies with greater predictability and stability.

Potential Benefits for Pharmacies

If the proposed changes are implemented, pharmacies can expect several benefits. First and foremost, eliminating retroactive DIR fees would provide pharmacies with more transparency and predictability in their reimbursement calculations. This change would enable pharmacies to plan their finances better and allocate resources for patient care services, staff training, and technological advancements.

Moreover, establishing a standardized methodology for calculating DIR fees would ensure consistency and fairness across the board. This would prevent arbitrary fee assessments and promote a level playing field for all pharmacies, regardless of size or affiliation. Furthermore, pharmacies would be able to focus on enhancing patient outcomes rather than being burdened by administrative complexities.

Preparing for the Changes

While the proposed DIR fee changes bring hope for pharmacies, pharmacy owners and operators must stay informed and actively engage in the rulemaking process. Pharmacies should monitor updates from CMS and industry organizations, participate in public comment periods, and advocate for their needs and concerns. Additionally, pharmacies should evaluate their business models, financial plans, and contracting strategies to effectively adapt to the potential changes. Independent pharmacies will face cash flow interruptions during the first quarter of 2024. They must pay retroactive DIR fees from 2023 and the new DIR fees at the point of sale. This means pharmacies will pay double the DIR fees during the initial part of 2024 until all retroactive fees are settled.


The upcoming DIR fee changes promise to relieve some of the financial burdens pharmacies face and improve their ability to provide quality care to patients. Eliminating retroactive fees and establishing standardized calculations would enhance transparency and predictability, fostering a more equitable reimbursement environment. However, pharmacies must remain engaged, adapt their strategies, and actively advocate for their interests to ensure the proposed changes align with their needs. The beginning of these changes will cause some initial problems, but being proactive and prepared will be very important with this transition. By doing so, pharmacies can navigate the evolving landscape and continue to serve their communities with dedication and excellence.