10/01/2026
This was not us, but it could have been because this happens to us several times a year.
I mailed off my PBM audit last week.
40 prescriptions.
182 total fills.
250 pages of documentation.
$61,805.87 in potential claw backs.
Every one of these prescriptions was filled for the correct patient, correct medication, correct strength, correct directions, and correct quantity.
Many of the prescriptions the PBM selected were medications that had recently gone generic—but at the time they were filled, the insurance company was still requiring us to dispense the brand name version.
For perspective, on two of these medications, we’re talking about roughly $500 for the brand version versus $10 for the generic.
Now that the plans have switched to covering the generic, I get to dig back through months of prescriptions and documentation to prove that when we dispensed the expensive brand, we did it because that was what the insurance required at the time.
I had to hire my relief pharmacist to work in my place for an entire day so I could gather the documentation and make sure I included everything that was required.
Then I printed the 250 pages of proof and mailed it all off.
And now we wait to find out whether they find a “discrepancy” that allows them to take money back.
This is part of what independent pharmacies are up against that most patients never see.
It’s not just reimbursement.
It’s the time. The paperwork. The payroll. The administrative burden. And the constant possibility that money we were paid months ago could be taken back.
$61,805.87 potentially on the line for prescriptions that were filled correctly.
This is why PBM reform matters.
Because pharmacists should be spending their time taking care of patients—not producing 250 pages of paperwork to prove they did their jobs correctly.
