RxRecoup

Idea

RxRecoup catches every prescription an independent pharmacy got paid below its own acquisition cost, and turns each one into a ready-to-file appeal. It ingests the pharmacy's wholesaler invoices and its dispensing software's claims export, matches every adjudicated fill against the actual invoice line it was bought on, flags every fill reimbursed below that true cost, and auto-drafts a state-specific Maximum Allowable Cost (MAC) appeal citing the correct statute and deadline. The pharmacy submits the appeal itself and keeps 100 percent of whatever it recovers.

Market gap

Independent pharmacies are reimbursed by PBMs off opaque, PBM-built MAC price lists, and a growing number of states now give them a legal right to appeal when that reimbursement falls below what the pharmacy actually paid its wholesaler. But exercising that right requires manually pulling the wholesaler invoice, matching it to the claim, knowing which of the differing state rules and deadlines applies, and drafting a compliant appeal, all inside a window as short as 30 days. No small pharmacy has staff for this at scale, so the money goes uncollected while pharmacies say the underlying reimbursement problem already threatens their survival.

Timing is right now for three reasons. First, the pain is at a documented high: NCPA's January 2025 survey of 8,000 independent pharmacy owners found 96.5 percent say Part D reimbursement threatens their business's viability, and 40.8 percent say they were paid below the National Average Drug Acquisition Cost on more than 40 percent of their Part D fills. Second, state appeal rights are actively expanding: Washington's E2SSB 5213 took effect January 1, 2026 and specifically strengthens appeal rights for pharmacies with fewer than 15 retail outlets, while Utah and Hawaii moved their own MAC appeal bills in 2026. Third, the only help available today is either a broad, analyst-driven reconciliation service, a law firm billing by the hour, or a PSAO that bundles appeal filing into a contract relationship the pharmacy has to join, none of which is a self-serve, flat-fee tool built only for this.

Total Addressable Market (TAM)

Bottom-up, using the pharmacy count as the base:

• 18,960 independent pharmacy locations in the US as of July 2025 (NCPA 2025 Digest, reported by Chain Drug Review, October 2025).
• Anchor plan average annual contract value: $199/month (Growth tier) x 12 = $2,388/year.
• TAM = 18,960 x $2,388 = approximately $45.3 million if every independent pharmacy adopted the tool.

SAM: NCPA's January 2025 survey found 40.8 percent of independent pharmacists were paid below NADAC on more than 40 percent of their Part D fills, a reasonable proxy for the share of the market feeling this pain acutely enough to buy now.

• SAM = 18,960 x 0.408 = approximately 7,736 pharmacies x $2,388 = approximately $18.5 million.

SOM: a realistic first 18 to 24 months for a small team selling through state pharmacy association channels and wholesaler co-marketing, at 4 percent penetration of SAM.

• SOM = 7,736 x 0.04 = approximately 310 pharmacies x $2,388 = approximately $740,000 ARR.

Monetization strategy

Flat monthly SaaS subscription, billed to the pharmacy owner, with no percentage-of-recovery cut. The pharmacy uploads its wholesaler invoice export and its dispensing software claims export (CSV); RxRecoup matches them, flags underpaid fills, and generates the appeal document. The pharmacy pays every month it wants the flagging and drafting service running, whether or not it files every appeal, the same way it pays for any other back-office SaaS tool. Keeping 100 percent of recovered dollars, instead of the percentage cut a GPO or consultant takes, is the core of why an owner keeps paying.

Pricing strategy

• Starter, $89/month: one location, up to 1,500 claims analyzed per month, up to 25 appeal drafts per month.
• Growth (anchor), $199/month: one to three locations, unlimited claim analysis and appeal drafts, deadline-tracking dashboard.
• Multi-location, $349/month: up to 15 locations under one account (matching the threshold Washington's new law itself uses for small-pharmacy protection), consolidated dashboard, priority support.

Entry point is Starter at $89/month, cheap enough for a single-store owner to try against one month of claims. Growth is the anchor because most independents operate one to three stores and will hit Starter's cap within the first upload.

Lead magnet

A free, no-signup MAC Below-Cost Recovery Calculator. The pharmacist enters last month's Part D claim count (a field is pre-filled with NCPA's national average of 40.8 percent below-NADAC fills, editable to their own number) and the tool estimates the dollars likely sitting unfiled right now, plus a one-page printable explainer of their own state's specific MAC appeal deadline and rights.

Social proof that the problem exists

1. NCPA January 2025 survey of 8,000 independent pharmacy owners and managers: 96.5 percent said PBM and Part D reimbursement threatened their business's viability, 40.8 percent said they were paid below NADAC on more than 40 percent of their Part D fills, and 30.3 percent said they were considering closing their business in 2025. https://ncpa.org/sites/default/files/2025-01/1.27.2025-FinalExecSummary.NCPA_.MemberSurvey.pdf
2. NCPA's independent pharmacy closures tracker: more than 300 pharmacies have closed since December 2024, and there are 4,100 fewer pharmacies today than four years ago, evidence the underpayment problem is already forcing real business failures, not just complaints. https://ncpa.org/sites/default/files/2026-01/IndependentsClosing_2025FlyerEdit.pdf
3. NCPA CEO B. Douglas Hoey's February 11, 2026 testimony to the House Energy and Commerce Committee named below-cost reimbursement directly as a systematic PBM practice harming pharmacies, evidence the problem is significant enough to reach a federal hearing. https://ncpa.org/newsroom/news-releases/2026/02/11/ncpa-ceo-congress-lower-costs-dissolving-health-care
4. Washington State's RCW 48.200.280, effective January 1, 2026, singles out pharmacies with fewer than 15 retail outlets under one corporate umbrella for stronger appeal protection, evidence state lawmakers see small independents specifically as the underserved population here. https://app.leg.wa.gov/RCW/default.aspx?cite=48.200.280
5. Frier Levitt, a health care law firm, publishes explainer content and sells legal representation just to help pharmacies use an appeal right they already hold on paper, evidence the process is inaccessible enough that pharmacies pay a lawyer rather than self-file. https://www.frierlevitt.com/articles/why-filing-mac-appeals-should-be-a-win-win-for-pharmacies/

Competitors

• Net-Rx (net-rx.com): a 20-plus-year reimbursement reconciliation company. Its Reimbursement Suite and RecRx products flag underpayments, including MAC and DIR fee issues, but delivery is built around a dedicated human Reimbursement Analyst who interprets the reports for the pharmacy.
• Frier Levitt: a health care law firm that represents pharmacies in individual MAC appeal disputes and broader PBM litigation, billed as legal services, reactive and case-by-case.
• Elevate Provider Network and PSAOs generally: pharmacy services administration organizations that negotiate contracts and can file MAC appeals as a membership benefit, but tie the pharmacy into that PSAO's specific network relationship.
• Dispensing software (PioneerRx by RedSail Technologies, WinPharm by TDS Health): process and adjudicate claims and can export reports, but per PioneerRx's own "Claim Assistance" vendor marketplace, MAC appeal handling is routed to third-party add-ons or manual staff work, not a native feature.

What competitors offer now

Net-Rx's RecRx report shows fee and adjustment line items after the fact; a human analyst still has to interpret them and pharmacy staff still have to manually file the correct appeal in the correct state format. PSAO-bundled appeal filing only covers disputes the pharmacy staff notices and flags manually, and only within that PSAO's own contracted network. Frier Levitt bills by the hour or retainer, which only pencils out for large-dollar disputes, not the steady drip of small below-cost fills that add up over a year. Dispensing software exports raw claims data but has no acquisition-cost matching, no state-specific appeal drafting, and no deadline tracking built in.

What can be done differently to attract customers

Ingest the pharmacy's own wholesaler invoice, the same document PBMs already require as appeal proof, and match it automatically line by line against every adjudicated claim pulled from whatever dispensing software the pharmacy already uses. No PSAO switch, no analyst relationship, no percentage cut on recovered dollars. The tool knows which state's MAC law applies and auto-generates the appeal already filled in with the claim, the invoice line, and the correct statute citation (Washington's 30-calendar-day clock under RCW 48.200.280, for example), then tracks every open deadline on one dashboard so nothing lapses silently. Entry is the free MAC Below-Cost Recovery Calculator, which puts a real, pharmacy-specific dollar number in front of the owner before they ever talk to anyone.