I’m Opening My Pharmacy’s Books. Here’s What Pharmacy Finance Actually Looks Like.

Today I’m going to do something you will not see from CVS earnings calls, PBM executive keynotes, or healthcare policy panels.

I’m going to open my books and show you my pharmacy’s actual finances.

Week after week I talk about transparency in healthcare. But nothing I can say carries more weight than showing the real numbers. So that’s what I’m doing.

As part of my annual review, I broke down every prescription dispensed at C.O. Bigelow in 2025, segmented by payment type, drug class, and PBM.

What I found made me genuinely sick.

Most people in healthcare are not comfortable with this level of transparency. Many can’t be. The system depends on opacity. Confusion is its greatest defense mechanism.

But if we want to understand why pharmacies are collapsing, we have to look at the math.

So let’s do that.

Before we get into the data, I want to address the most obvious reaction head-on.

Some people will look at these numbers and assume this is a management problem. That I’m simply not running an efficient business.

I reject that completely.

C.O. Bigelow is not a weak operator.

If dispensing could work anywhere in America, it would work here.

We are the oldest operating pharmacy in the country. We are high-volume. We are well capitalized. We are extremely aggressive and sophisticated in our purchasing. We employ a full-time purchasing manager whose primary job is negotiating and price-shopping across multiple wholesalers. We arbitrage constantly. We squeeze acquisition cost harder than almost any independent pharmacy in the country.

Most pharmacies do not have these advantages. In most stores, the owner is simultaneously the primary pharmacist, the purchasing manager, and the business operator. They simply do not have the time or resources to operate this way.

So what you’re about to see is not a worst-case scenario.

It’s a best-case one.

In 2025, C.O. Bigelow dispensed 130,492 prescriptions.

Across all pay types, those prescriptions generated:

That’s a 12.25% gross margin.

In pharmacy, that’s considered healthy.

It shouldn’t be.

Because that topline hides where the money actually comes from—and where it disappears.

When you strip out cash (out-of-pocket) prescriptions and look only at insurance-billed scripts, the economics change immediately.

In 2025, we filled 116,467 insurance prescriptions, or 89.25% of our total volume.

Those prescriptions generated:

That’s an 8.7% gross margin.

Eight point seven.

And that’s before rent, labor, utilities, compliance, audits, retroactive DIR fees, employee benefits, and the cost of floating millions of dollars while waiting to be paid.

No normal retail business survives on margins like that.

But it gets worse.

Let’s talk about brand medications.

These are the drugs most people assume pharmacies make money on. They’re expensive, high-profile, and often life-saving.

In 2025, C.O. Bigelow dispensed 17,293 brand prescriptions billed to insurance.

Those prescriptions generated $11.77 million in revenue.

Our total gross profit on those prescriptions?

$20,365.

That’s not a typo. Five digits.

That’s a 0.17% gross margin on nearly $12 million in brand drug revenue.

On average, we made about $1.18 per prescription. That barely covers the vial, label, and bag.

From a purely financial perspective, I would have been better off putting that cash into a Treasury bill yielding a conservative 3.5%, which would have produced over twenty times more profit.

Expensive drugs do not subsidize pharmacies.

They endanger them.

Brand drugs are not profit centers. They are financial landmines.

Now, because I like pain, let’s talk about GLP-1s.

In 2025, C.O. Bigelow dispensed 2,169 GLP-1 prescriptions billed to insurance.

That’s less than 2% of our total prescription volume.

Those prescriptions generated $2.38 million in revenue.

Our acquisition cost?

$2.42 million.

Our gross profit?

–$40,998.

A negative 1.69% margin.

We lost over $40,000 dispensing a tiny fraction of our prescriptions.

GLP-1s didn’t break pharmacy economics. They exposed them. They simply concentrated everything broken about the system into one drug class: massive upfront cost, zero pricing control, delayed reimbursement, and no tolerance for error.

The hype made the problem impossible to ignore.

If you want a deeper explanation of how this works, I wrote about it in the first Drugstore Cowboy newsletter I ever sent.

Now let’s stop speaking abstractly and talk about PBMs.

Specifically: OptumRx.

In 2025, our largest insurance relationship was with OptumRx. We filled 21,165 prescriptions under their top plan.

Those prescriptions generated $1.96 million in revenue.

Our acquisition cost was $1.89 million.

Our gross profit?

$70,520.

That’s a 3.6% gross margin, or roughly $3.33 per prescription.

On paper, that’s “positive.”

In reality, it’s catastrophic.

That margin leaves no room for labor, storage, compliance, capital risk, audits, or retroactive fees. And this is best-case purchasing at one of the most aggressively managed independent pharmacies in the country.

I’m using OptumRx as the example because they were our top PBM, but this is no different for Caremark, Express Scripts, Cigna, or any of the others.

Across every category in this data, one truth repeats.

Dispensing is no longer a viable business model.

Pharmacies are expected to:

All without interest.
All without guarantees.
All without leverage.

That isn’t dispensing.

It’s underwriting.

And unlike banks, pharmacies cannot opt out.

Don’t kid yourselves. I’m not asking for pity, and I’m not asking for a handout. This is simply the reality.

So what should I do? Stop filling brand drugs? Stop taking insurance? Turn away patients on GLP-1s, HIV meds, or cancer therapies?

I didn’t become a healthcare provider to turn people’s pain and suffering into line items. I did it to help.

I don’t want to be put in the position where I need answers to those questions.

This is what happens when patient care and financial incentives are no longer aligned.

And until those incentives are realigned, this problem will continue to accelerate.

C.O. Bigelow survives despite dispensing economics, not because of them.

We vaccinate.
We counsel.
We price creatively.
We fight wholesalers.
We build revenue streams that are not controlled by PBMs.

Dispensing does not keep the lights on. It actively works against that goal.

And I want to be crystal clear about this:

These numbers are almost certainly better than 99% of pharmacies in America.

If dispensing doesn’t work here, it doesn’t work anywhere.

I didn’t start this piece knowing exactly where it would end. I just knew I couldn’t shake how much worse the economics have become year after year.

Harsh reality matters. What we lose when we ignore it is the human side of healthcare.

There is no margin for error anymore. And I believe many of you will soon see your hometown pharmacies operating very differently than they have in the past.

We can’t go on pretending this isn’t happening.

Adapt or die.

It’s going to be a very interesting year.

Alec Wade Ginsberg, PharmD, RPh
4th-Gen Pharmacist | Owner & COO, C.O. Bigelow
Founder, Drugstore Cowboy