My Pharmacy's $2 Million Ozempic Problem

My Pharmacy’s $2 Million Ozempic Problem

Over the past year, my pharmacy spent $2m+ buying GLP-1s and lost $26k+ dispensing them. Let me explain…

It is June 2025. If you don’t know what a GLP-1 is, I’m surprised you have enough internet literacy to access this newsletter. But in case you’ve been living in a bunker for the past three years, when I say “GLP-1” I’m referring to the medication class of “Glucagon-Like Peptide-1 Receptor Agonists” that includes Ozempic, Wegovy, Mounjaro, and Zepbound. The 2020’s will be defined by these meds, and I don’t think it’s a stretch to predict that we will look back on American history as “B.GLP1.” and “A.GLP1.”

I’m sure at this point you’re all sick of reading about them, but there’s a part of the GLP-1 story you’re not hearing: they are running pharmacies out of business.

Over the past year, my pharmacy filled 1,800+ GLP-1 prescriptions through insurance. We spent $2,000,000+ to purchase the medication…

…and we lost $26,000+ doing it.

Not made a thin margin.
Not broke even.
Lost money.

And that loss doesn’t even include clawbacks, DIR fees (don’t worry if you don’t know what these are - we’ll get there), labor, or inventory overhead. That’s just the basic: “we bought it for this price and sold it for that price” number. The real loss is far worse.

This is Not a Business Model - It’s a Slow Bleed

Most patients assume that if their insurance covers the medication and their co-pay is reasonable, everything must be working. They see Novo Nordisk and Eli Lilly printing money and figure every player in the supply chain must be cashing in.

But what they don’t see is that, for every prescription we fill (not just GLP-1s), we’re often reimbursed less than what we paid to acquire the drug.

I’m sure you’re wondering how this is possible. So here’s a simplified version of how it works: 

Pharmacies buy drugs from wholesalers like Kinray, AmerisourceBergen, or McKesson. A one-month supply of a GLP-1 might cost us $1,200 to purchase (prices fluctuate daily, just like the stock market, but that’s a topic for another day).

When you refill your prescription, we submit the claim to your PBM (Pharmacy Benefit Manager - aka, the Mafia of the Healthcare World) and say:

The PBM replies:

In a typical case, we’ll get back $1,180 - before additional fees and retroactive clawbacks.

That’s a guaranteed loss. And we have zero recourse.

So Why Would Any Pharmacy Agree to That?

That’s the question we’re asking ourselves.

We say yes to GLP-1s because we care about our patients. I don’t want my pharmacy to be one that just says, “we’re out of stock,” if it isn’t true. I got into this business to help people in need, not leave them high and dry, and I know how transformative these medications can be.

And since I promised you no bullshit in this newsletter, I’ll give you the whole truth:

We also say yes because if we told patients, “Sorry, we can’t fill this because your PBM reimburses us below cost,” the patients might complain, and then the PBM could (and likely would) terminate our contract.

You might ask, “Why would you sign that contract in the first place?”

We don’t have a choice.

The three largest PBMs in the country - CVS/Caremark, Cigna/Express Scripts, and UnitedHealth/OptumRx - control ~80% of all prescriptions in America. While they may not hold a literal gun to my head, I can’t say no. Losing access to even one would be a death sentence for a pharmacy like mine.

We Can’t Keep Subsidizing the System

Here’s the raw math from the past 12 months:

Pharmacy in this country is a business whether we like it or not. I'd love to give out free medication to everyone who needs it - but I need to pay rent, my staff, and yes, myself.

Imagine pitching a business with those numbers to a potential investor.
They’d laugh you out of the room.

We’re lighting cash flow on fire just to stay in the game. And this is only one class of medication. 

I’ll give you another example. Over the same time period, my pharmacy filled almost exactly the same number of prescriptions for HIV medication. We spent $3,300,000+ to acquire those drugs and made under $75,000 before labor, etc… For those keeping score at home, that means between just HIV and GLP-1 we filled 3600+ scripts at around $5,400,000 acquisition cost to make less than $50,000 (<1% margin!!). This is why Rite Aid went bankrupt (twice), Walgreens is closing 1200 stores, and your neighborhood pharmacy doesn’t exist anymore. You’ve gotta sell a shitload of TUMS (or C.O. Bigelow Rose Salve 😉) to make up for numbers like that.

So Where Does That Leave Us?

Some pharmacies have stopped carrying GLP-1s altogether. Others are moving patients to cash-pay only or compounding alternatives. Some are politely telling patients what I just shared with you and asking them to mercifully fill their scripts somewhere else. And of course, many are just quietly eating the losses, hoping something changes before they’re forced to close their doors for good.

At C.O. Bigelow, we’re taking a hard look at how we move forward.

What’s clear is this:
The current model is unsustainable - for us, for patients, and for every independent pharmacy trying to do the right thing.

GLP-1s are fantastic drugs. But right now, they’re playing a large part in destroying the foundational healthcare hubs of countless American communities.

I’m not looking for sympathy. I just want my first letter to give you a little taste of how broken the system really is and how much there is for me to show you underneath the hood.

Like What You Just Read?

This is the kind of truth you’ll get every week in Drugstore Cowboy - pulling back the curtain on the American drug industry from inside the belly of the beast.

If you’re left with questions like…

• If pharmacies aren’t making money on GLP-1s… who is?
  

• Does it work the same with compounded Ozempic?
  

• What does a PBM actually do?
  

• You must make money on something, right?
  

• Why should I care if community pharmacies disappear?
  

• It can’t have always been like this - how did we get here?

…you came to the right place.

More soon.

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