PBM's "update" reimbursement...

PBMs will often notify pharmacies of updated reimbursement rates (usually via email). Even if a claim did not result in a financial loss, the pharmacy may reverse and rebill the claim to capture the higher reimbursement.

⚠️ Caution: Always compare the original, appealed, and updated rates before reversing and rebilling--THIS COULD BE LOWER AMOUNT!

Why This Matters

Yes, reversing a claim to accept a lower payment may feel counterintuitive—but it serves a larger purpose.

PBMs are legally required under state and federal laws (e.g., MAC pricing rules) to:

• Maintain updated and accurate reimbursement rates

• Apply those rates fairly to all similarly situated pharmacies

Sending an email about updated rates does not prove they are being applied equitably.

You Can File a PBM Complaint if this is not accurately being managed by the PBM!!!!

Evolving Process

This situation—where a PBM’s updated rate is lower than a prior approved appeal—was first identified in April 2025. Processes for managing these scenarios are still developing.

Stay vigilant, document everything, and continue to act. Your diligence is crucial to systemic accountability.

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