PBM Appeals: Frequently Asked Questions

What is an "underwater" claim? An underwater claim is a prescription where the amount the PBM reimbursed you is less than your actual cost to acquire the drug from your wholesaler. Pharmacy Marketplace identifies these automatically by comparing what you were paid against your acquisition cost (ACQ) and/or published benchmarks like NADAC.

Which claims are eligible for appeal? Generally, any commercial insurance claim or state Medicaid claim where you were reimbursed below your acquisition cost is eligible. Federal programs, including Medicare Part D, Tricare, and plans under federal jurisdiction, are not eligible. Claims from plans like hospital indemnity, accidental injury, or specified disease coverage are also excluded.

How does Pharmacy Marketplace find these opportunities? The system pulls your claims data and compares the PBM's payment against your actual wholesale purchase records. When the payment falls below your cost, an opportunity is automatically created. The acquisition cost is calculated using your most recent invoice for that specific drug prior to the fill date.

How quickly do I need to act after an opportunity appears? Filing deadlines vary by state and are counted from the date the prescription was filled, not the date you see the opportunity in the system. Timelines can range from as few as 3 days to as many as 30+ days, depending on your state's regulations. Check the Due Date shown on each opportunity and prioritize accordingly. Expired opportunities cannot be appealed.

Do I submit the appeal directly through Pharmacy Marketplace? Currently, you'll use the information in Pharmacy Marketplace to complete the appeal through your PBM's own portal. Pharmacy Marketplace stores all the relevant claim details so you can copy them directly into the PBM's form. Once submitted, you mark the appeal as submitted in Pharmacy Marketplace so it's tracked. 

What documentation do I need to submit an appeal? Most PBMs require your wholesaler invoice showing you purchased the drug at or above the reimbursed amount, on or before the fill date. Pharmacy Marketplace pulls invoice data automatically where possible. You can view and upload supporting documents within each opportunity.

What happens if the PBM doesn't respond? If the PBM doesn't respond within the required timeframe, update the opportunity status to No Response and consider escalating to an external appeal. States with defined response timelines give you grounds to escalate; states without defined timelines can be trickier, but it's still worth pursuing.

What is an external appeal? If your initial appeal is rejected or ignored, most states allow you to escalate to an independent external review body; typically a state Insurance Commission or a third-party administrator. Pharmacy Marketplace tracks this as a separate step in the workflow. You generally have 30 days from the PBM's final decision to file, though timelines vary by state.

How do I know if an appeal was financially successful? Once an approved appeal is fully processed, record the original paid amount and the final adjudicated amount in the opportunity. Your recovered revenue is tracked in your appeals dashboard, so you can see total amounts recovered over time.