Two pharmacies with identical scripts can earn very different money, because what you keep depends on which PBMs you're contracted with and how much each pays per claim. Worse, heavy reliance on one PBM is a structural risk: a single contract change can swing the whole store. This dashboard shows where revenue comes from, how profitable each PBM is per claim, and how concentrated — and therefore exposed — the business is.
What this report answers
Who pays us, how well, and how dangerous is the concentration? The Payer Concentration page carries total net reimbursement, claim volume, net profit per claim, top-PBM concentration rate, cash/discount-card rate, and average net per claim, then ranks net reimbursement by PBM, shows claim share by payer type, and ranks profit per claim by PBM so a high-volume/low-profit contract is impossible to miss.
The metrics that matter
Net profit per claim by PBM is the contract-decision number — a PBM can drive a lot of volume and still lose money per fill. Top-PBM concentration rate is the risk gauge: the more of your claims ride on one PBM, the more a rate cut or contract change hurts. Cash/discount-card rate is the part of the book paid outside insurance, often at different economics worth understanding on its own.
Why the data is trapped across the systems
Payer mix needs net reimbursement and the DIR-adjusted profit per claim, by PBM — which means joining the PBM remittances (835/CSV) to the dispensing record in PioneerRx or QS/1 and to acquisition cost. The dispensing system knows which plan adjudicated a claim, but not what it ultimately paid net of fees or what the drug cost, so true per-PBM profitability only exists once those sources are reconciled.
How to read it
Start with the Contract Profitability scatter: profit per claim versus volume per PBM. The dangerous quadrant is high volume, low or negative profit — a contract to renegotiate or exit. Then read top-PBM concentration: if one PBM dominates your claims, that's your single biggest revenue risk regardless of how it pays today. Use net reimbursement by payer type to understand the mix and the cash/discount-card share to size the non-insurance book.
This is the mix-and-rate side of revenue; the AR & Rejections report covers whether you actually collected it. The sample uses synthetic PBMs and made-up amounts — no real data.
Metrics it tracks
| Metric | What it means |
|---|---|
| Total Net Reimbursement | Net dollars paid across all adjudicated claims in the period. |
| Claim Volume | Adjudicated claim rows in the period. |
| Net Profit per Claim | Total gross profit ÷ claim count — blended profit earned per claim. |
| Top-PBM Concentration Rate | Claims tied to the single largest PBM ÷ all claims — concentration exposure. |
| Cash / Discount-Card Rate | Cash and discount-card claims ÷ all claims — share paid outside insurance. |
| Average Net per Claim | Total net reimbursement ÷ claim count. |
Used by: Owner-pharmacists gauging payer concentration risk and weeding out PBM contracts that lose money per claim
Frequently asked questions
What is PBM concentration risk?
It's the exposure created when a large share of your claims depends on a single PBM. If that PBM cuts rates, changes its MAC list, or alters contract terms, the impact is outsized. The top-PBM concentration rate makes that risk visible so it can be managed before a contract change forces the issue.
How can a PBM contract lose money even at high volume?
Because reimbursement per claim — net of DIR/GER fees — can fall below your cost and overhead even when the PBM sends a lot of scripts. Net profit per claim by PBM separates the contracts that pay from the ones that just keep you busy, which is why volume alone is a misleading guide.
Can I build this on my own claims data?
Yes. Export your adjudicated claims and PBM remittances with acquisition cost and use this as a template — we model per-PBM net reimbursement and profit into a Power BI report. The sample uses synthetic data so there's no PHI here.
Build this report on your own data
Clone this Independent pharmacies template — describe it and we’ll generate sample data so you can try it free, or upload your own export. You get a fully modeled, branded Power BI project that opens in Power BI Desktop.
Use this as a template →