The same generic can cost very different amounts at different pharmacies. Most of that gap has little to do with the medicine and a lot to do with who pays the pharmacy, and how much.
The short answer: for six of the most common generics, the medicine itself costs a retail pharmacy about $0.31 to $1.22 for a month, by the federal government's own survey. What you pay on top of that covers the pharmacy's work, and when insurance pays, a pharmacy benefit manager (PBM) sets that amount. Some PBM rates fall below what the pharmacy paid for the drug, which is one reason neighborhood pharmacies close. You can often pay less by comparing cash prices, checking whether cash beats your copay, and trying cost-plus pharmacies or discount cards.
Why pharmacies say they are underwater
Drug Topics reported on October 18, 2026, in a video interview by Brian Nowosielski with attorney A.J. Barbarito of Frier Levitt, that payment below acquisition cost and opaque "maximum allowable cost" (MAC) price lists remain the biggest financial threats to independent pharmacies heading into 2027. "A pharmacy cannot sustain its business if it is receiving reimbursement that does not cover the cost to acquire the drug," Barbarito told Drug Topics.
The story points to a lawsuit by Florida Attorney General James Uthmeier against two PBMs, Prime Therapeutics and Express Scripts, alleging illegal price fixing. The complaint says that after Prime adopted Express Scripts' lower rates, payments dropped for about 80% of brand-name drugs and 70% of generics. One pharmacy outside Orlando saw its payment for one drug fall 45%, turning a profit into a $15.45 loss on each fill. Both companies denied wrongdoing, Healthcare Finance News reported.
Federal settlements with Express Scripts and CVS Caremark require those two PBMs to offer pharmacies "cost-plus" contracts: the drug's actual cost plus a dispensing fee. Barbarito warns the orders set no minimum fee, so a small fee can still leave a pharmacy with no margin.
What the pharmacy pays versus what you might pay
NADAC, the National Average Drug Acquisition Cost, is a weekly CMS figure built from surveys of what chain and independent pharmacies pay for each drug. We set it next to two public cash prices.
| Generic, 30-day supply | Pharmacy's average cost (NADAC) | Cost Plus Drugs cash price | Walmart Prescription Program |
|---|---|---|---|
| Atorvastatin 20 mg, 30 tablets | $0.84 | $5.41 | Not on list |
| Lisinopril 10 mg, 30 tablets | $0.54 | $5.39 | $9 |
| Metformin 500 mg, 60 tablets | $0.87 | $5.64 | $9 |
| Sertraline 50 mg, 30 tablets | $1.04 | $5.69 | Not on list at 50 mg |
| Levothyroxine 50 mcg, 30 tablets | $1.22 | $5.91 | $4 |
| Amlodipine 5 mg, 30 tablets | $0.31 | $5.20 | $9 |
Assumptions: prices checked October 19, 2026. NADAC is the drug cost only, from the CMS file dated October 14, 2026. Cost Plus prices include its $5 dispensing fee; standard shipping adds $5.25 per order. Walmart's prices come from its program list effective March 24, 2025, still linked from its site, and may be higher in some states.
What the table shows
- The pill is the cheap part. At Cost Plus, the flat $5 fee is 84.6% to 96.2% of the price. Any pharmacy's price on these drugs is mostly the cost of filling the prescription.
- Buying power matters. Cost Plus's per-pill price is 25.3% to 51.1% below the national average a retail pharmacy pays. A large buyer can list a per-pill price below what the average retail pharmacy pays to acquire the drug.
- That is the squeeze. When a PBM pays near the drug cost and adds a small fee, the pharmacy's rent, staff, and time go unpaid. Drug Topics reports that appealing a single underpaid claim often costs more labor than the claim is worth.
What you can do
- Compare cash prices. Check a cost-plus pharmacy, a big-box program list, and a discount card price before you fill.
- Ask whether cash beats your copay. For cheap generics, it sometimes does. Ask your pharmacist, and ask whether a cash purchase counts toward your deductible.
- Look at subscriptions if you take several generics. Amazon's RxPass charges Prime members $5 a month for a list of common generics. Check that your drug and state are eligible.
- Keep a pharmacy you trust. A local pharmacist who knows your medicines is worth something. Ask whether they will match a price you found.
- Talk with your prescriber or pharmacist before you change a medicine, dose, or supply length.
Where Temi fits
Temi does not sell these medicines. If you already take a non-controlled medicine and need a refill prescription, a licensed physician reviews your request within 48 hours, often sooner. The review costs $15, or $0 with Temi Care. If approved, the prescription goes to the pharmacy you choose, whether that is a cost-plus pharmacy, a big-box store, or the neighborhood pharmacy you want to keep, and you pay that pharmacy for the medicine. Temi serves patients located in Arizona, California, Colorado, Delaware, Florida, Michigan, Missouri, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin. See how refills work.
Sources
- Brian Nowosielski and A.J. Barbarito, "PBM Underpayment Persists as Cost-Plus Brings New Strain | NCPA 2026," Drug Topics, October 18, 2026. https://www.drugtopics.com/view/pbm-underpayment-persists-as-cost-plus-brings-new-strain-ncpa-2026 (checked 2026-10-19)
- Susan Morse, "Florida AG sues Prime Therapeutics, Express Scripts alleging price fixing," Healthcare Finance News, August 31, 2026. https://www.healthcarefinancenews.com/news/florida-ag-sues-prime-therapeutics-express-scripts-alleging-price-fixing (checked 2026-10-19)
- A.J. Barbarito and S.L. Bennet, "FTC's Caremark settlement: what it means for pharmacies, PSAOs, and wholesalers," Frier Levitt, August 13, 2026. https://www.frierlevitt.com/articles/ftc-caremark-settlement-pharmacies-psaos-wholesalers/ (checked 2026-10-19)
- CMS, "NADAC (National Average Drug Acquisition Cost) 2026," data.medicaid.gov, week as of October 14, 2026. https://data.medicaid.gov/dataset/fbb83258-11c7-47f5-8b18-5f8e79f7e704 (checked 2026-10-19)
- Cost Plus Drugs pricing API: atorvastatin 20 mg, lisinopril 10 mg, metformin 500 mg, sertraline 50 mg, levothyroxine 50 mcg, and amlodipine 5 mg tablets. https://api.costplusdrugs.com/pricelist/cpd (checked 2026-10-19)
- Walmart, "Walmart Prescription Program: Guide to low-cost prescriptions," effective March 24, 2025, linked from https://www.walmart.com/cp/4-prescriptions/1078664. https://i5.walmartimages.com/dfw/4ff9c6c9-119c/k2-_c3e2f451-7a63-414e-aac2-e3defc13ef60.v1.pdf (checked 2026-10-19)
- Amazon Pharmacy, RxPass. https://pharmacy.amazon.com/rxpass (checked 2026-10-19)
- Temi refill service page. https://usetemi.com/prescription/refills (checked 2026-10-19)
