How to Spot Red Flags in Pharmacy Benefit Management
Is Your PBM Working for You…Or Against You? How to Ask the Right Questions and Spot Red Flags in Pharmacy Benefit Management
Pharmacy benefits shouldn’t feel like a guessing game. But for many plan sponsors, that’s exactly what it becomes. Hidden fees, unclear pricing structures, and limited access to data can make it tough to tell whether your PBM is truly aligned with your goals - or quietly profiting at your expense.
At ProCare Rx, we believe the best way to fix that is simple: transparency. When you know what questions to ask, you can start to see who’s really working in your best interest.
Start with the Basics
If you’re unsure whether your PBM is helping or hurting your plan performance, ask these straightforward questions:
- Do you adjudicate claims in-house?
- Do you own your own mail order pharmacy?
- Do you take spread on generic drugs?
If the answers aren’t clear - or worse, avoided - you’ve got your answer. Lack of clarity usually means there’s something to hide.
Yes, Transparent Pricing Exists
It’s a myth that opaque pricing is just “how the industry works.” True transparency is not only possible, it is being done. ProCare Rx is among the few PBMs offering fully pass-through pricing. That means you see exactly what a drug costs, where every rebate goes, and how your pharmacy dollars are being spent. No games. No hidden margins. Just clean, accountable pricing.
Smart Questions to Include in Your Next RFP
Want to separate the transparent PBMs from the rest? Try adding these questions to your next pharmacy request for proposal:
- How do you make money?
- Will you share 100% of rebates?
- Do I have full access to and ownership of my data?
- Can you support specialized needs like 340B or international sourcing?
These questions uncover financial motivations, data accessibility, and service capabilities - all critical for making a sound, strategic PBM decision.
Clarity Is Possible
Pharmacy benefits don’t have to be confusing. When you ask the right questions, you find the right partners. And when you work with a PBM built on transparency, flexibility, and client control, you unlock savings and performance that are sustainable.
If you're ready to expect more from your PBM, ProCare Rx is ready to deliver.
About ProCare Rx
ProCare Rx is a privately held, independent pharmacy benefit manager (PBM) that has empowered healthcare and self-insured organizations since 1988. We provide fully integrated, in-house solutions—including claims adjudication, clinical program design, pharmacy network access, cost containment, and data analytics—all supported in the U.S. Our flexible, transparent model serves self-insured employers, third-party administrators (TPA), brokers, health plans, health systems, managed care organizations (MCO), unions, workers’ compensation programs, Medicare, Medicaid, hospices, and other PBMs. With a proprietary technology platform, commitment to ethical operations, and a focus on lowest net cost, ProCare Rx delivers long-term value, clinical performance, and trusted pharmacy benefit partnerships.
Media Contact:
Marc Cohen, VP, Marketing and Sales
marketing@ProCareRx.com
