Using NADAC Data for PBM Reimbursement Negotiations
By Dylan Sanson, Pharmacist & Pharmacy Manager · Published
Pharmacy benefit manager (PBM) reimbursement rates don't always keep pace with actual drug costs. NADAC data gives independent pharmacies the transparency they need to push back on unfair rates.
How Do You Identify Underwater Claims?
An "underwater" claim occurs when your PBM reimburses you less than your actual acquisition cost. By comparing PBM payments against current NADAC prices, you can identify exactly which drugs are losing money — and by how much.
How Do You Build Your Case with Data?
When approaching PBMs for rate adjustments, come prepared with specific examples showing your acquisition cost (backed by NADAC) versus their reimbursement. Track trends with NADAC Lookup Pro price history charts for compelling visual evidence.
What Should You Do Next?
- Run weekly reports comparing your top 50 dispensed drugs against NADAC
- Flag any drug where reimbursement is below NADAC + a reasonable dispensing fee
- Document trends — if a drug's NADAC has risen 15% but reimbursement hasn't moved, that's your evidence
- Present findings in contract renewal negotiations