Every independent owner has heard the consultant's line: find the scripts you're filling below cost. This dashboard is that hunt, made continuous. It flags every claim where net reimbursement landed under acquisition cost, totals the loss, separates the losses you can appeal from the ones you simply have to stop dispensing, and hands the billing person a worklist instead of a hunch.
What this report answers
How much money are we losing on below-cost claims, and where is it concentrated? The Loss Exposure page leads with the six KPIs — underwater claim count, underwater loss dollars, underwater claim rate, below-MAC claim count, appealable loss dollars, and total claims reviewed — then breaks the loss down by PBM, by drug, and by fill month so a single bad contract or a single problem drug stops hiding inside the average.
The metrics that matter
Underwater loss dollars is the number that gets attention, but underwater claim rate is the one that tells you whether this is a systemic contract problem or a few outliers. Below-MAC claim count matters because those are the claims where the PBM reimbursed under its own MAC list — the strongest basis for a price appeal. Appealable loss dollars splits the recoverable loss from the loss you can only avoid by changing what or for whom you dispense.
Why the data is trapped across the systems
A claim is only "underwater" once you compare two numbers that never meet in one system: net reimbursement from the PBM remittance (835/CSV) and acquisition cost from the wholesaler portal (McKesson, Cardinal, AmerisourceBergen), keyed to the dispense record in BestRx or your dispensing platform. The below-MAC flag needs the PBM's MAC list on top of that. No dispensing system computes this, which is why below-cost scripts keep filling until someone reconciles by hand.
How to read it
Work the Appeal Worklist first: it's filtered to underwater claims and shows claim, drug, NDC, PBM, net reimbursement, acquisition cost, loss, the below-MAC flag, and whether the claim is appeal-eligible — the exact fields a MAC appeal needs. Read the loss-by-PBM bar to decide which contracts are structurally unprofitable, and the loss-by-drug bar to find products to source cheaper or stop carrying. The appeal-eligible-vs-not stacked bar by PBM tells you how much of the bleed is recoverable versus how much demands a dispensing decision.
The sample here uses synthetic claims and made-up dollar amounts — no real remittances or PHI.
Metrics it tracks
| Metric | What it means |
|---|---|
| Underwater Claim Count | Claims where net reimbursement fell below acquisition cost. |
| Underwater Loss Dollars | Total below-cost loss summed across underwater claims. |
| Underwater Claim Rate | Underwater claims ÷ all reconciled claims — the share dispensed below cost. |
| Below-MAC Claim Count | Claims reimbursed under the PBM's MAC (Maximum Allowable Cost) list price. |
| Appealable Loss Dollars | Loss dollars on claims flagged eligible for a MAC-price appeal. |
| Total Claims Reviewed | All reconciled claim rows in the period. |
Used by: Owner-pharmacists deciding which drug/PBM combinations to stop dispensing or file MAC-price appeals on
Frequently asked questions
What makes a pharmacy claim 'underwater'?
A claim is underwater when the net reimbursement you ultimately receive — after DIR/GER fees — is less than the acquisition cost of the drug you dispensed. You lose money filling it. Spotting these requires joining PBM remittance data to wholesaler cost, which no single dispensing system does on its own.
Which below-cost claims can I actually appeal?
The strongest candidates are claims reimbursed under the PBM's MAC (Maximum Allowable Cost) list price — the below-MAC claims. The report flags appeal-eligible claims and totals the appealable loss dollars so you can prioritize MAC-price appeals by dollar impact rather than chasing every loss.
Can I build this on my own claims data?
Yes. Export your dispensing data, PBM remittances, and wholesaler acquisition cost and use this as a template — we model it into a Power BI report with the underwater and appeal flags computed for you. The sample uses synthetic data so there's no PHI in what you see 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 →