The Best-Kept Secret in Pharmacy: How to Actually Recover Your Underwater Claims

Underwater claims have become an accepted cost of doing business in pharmacy. When you try to explain the concept to owners of other small businesses, they look at you like you're crazy. And honestly? They're not wrong to be shocked.

Selling a product for less than you paid for it isn't a business model, it's a path to bankruptcy. Just ask Rite Aid. Or look at Walgreens going private with massive store closures on the horizon. If two of the largest chain drugstores can't make this system work, it proves what independent pharmacies have been saying for years: the system has been broken for a while. We're either going to stabilize, or we're going to see massive closures and pharmacy deserts across the country.

There's Hope But Most Pharmacies Don't Know About It

Here's the best-kept secret: state-level reform laws now allow pharmacies to take action on commercial negative reimbursement claims. Real action. With real results.

At Pharmacy Marketplace, we tackle the most frustrating and confusing problems in pharmacy operations. When we learned about these state laws, we had to ask: if the solution exists, why aren't pharmacies using it? So we dug in and researched the gaps. Here's what we found.

Myth #1: "The Laws Won't Be Enforced and PBMs Won't Pay Anyway"

We hear this all the time. Pharmacies assume that even if they file appeals, PBMs will just ignore them.

The truth? Most pharmacies haven't executed the process in alignment with their state law requirements. Without proper execution, the laws don't have teeth and that's been a common problem for decades in PBM reform.

When you follow the process correctly, PBMs are legally required to respond. They have to pay. But if you cut corners or skip steps, you're giving them an easy out.

Myth #2: "The Appeal Process Takes Too Much Time"

This one makes sense on the surface. Why would you put someone on a task that seems low-value for the time involved?

The truth? When the process is organized, automated, and built into your workflow, the time spent is minimal compared to the money you recover. If you allocate a pharmacy tech to this task for a couple of hours a week to file and track appeals, the ROI is substantial. We're talking real dollars flowing back into your business, not theoretical savings.

Myth #3: "It's My PSAO's Job to File Appeals"

Many pharmacies assume their PSAO should handle this. And if they're not doing it successfully, why bother trying on your own?

The truth is that PSAOs have limitations. Blanket-level appeals don't align with the specific language in state laws. The law typically requires that the actual invoice proving negative margin be attached to each individual appeal in the portal. If the cost is approximated or if you don't follow your state's regulations to the letter, PBMs won't comply. Why should they?

Pharmacies need to take action on their own store-level appeals. This has been a blind spot for years, and it's costing you money every single day.

What Would It Mean to Your Bottom Line?

Think about this: if you added back even half of all your underwater claim dollars to your pharmacy profit, what would that number be? For most pharmacies, it's significant, potentially thousands of dollars per month.

Is it worth learning a simplified process that will save you time, save you money, and put the power back in your hands?

Real Results from Real Pharmacies

Don't just take our word for it. Here's what one of our customers told us:

"I've owned my pharmacy for 6 years and gave up on appeals 5 years ago. I have used the Pharmacy Marketplace Appeals feature for 3 weeks and have submitted over 250 claims with almost 100% success rate. I don't stress about claims showing a loss anymore, because I know I am able to submit an appeal through the Marketplace website and they'll help me get my money back."

Three weeks. Over 250 claims. Nearly 100% success rate. Those aren't theoretical dollars, that's real money back in the bank.

Take Control of Your Profit

The system may be broken, but that doesn't mean you're powerless. State laws are on your side, and with the right tools and process, you can turn underwater claims from an accepted loss into recovered revenue.

Set up a demo today to learn more about how Pharmacy Marketplace is stabilizing pharmacy profit one appeal at a time.