Before You Switch PBMs, Know What a Smooth Transition Requires

Choosing a pharmacy benefit manager is about more than comparing discounts and rebate guarantees. The request for proposal should help employers and benefits consultants understand how each offer will work after the contract begins . The best questions require clear, written answers that can be measured, audited, and added to the final agreement. As you evaluate your pharmacy plan design, make sure your RFP addresses these five areas. 1. Can We Audit Every Part of the Pharmacy Benefit? A simple “yes” is not enough. Ask whether the plan can review claim-level data, pricing, rebates, fees, and payments involving subcontractors or downstream vendors. The plan should be able to choose an independent auditor, use a reasonable lookback period, and share findings with its internal team and advisors. Federal rules also limit contract terms that block group health plans from accessing certain claims and cost information. The RFP response should explain the audit process, timing, data format, and what happens when an error is found. 2. Is Pricing Fully Pass-Through Across Every Channel? Pricing may work differently at retail pharmacies, mail-order pharmacies, and specialty pharmacies. Ask the PBM to state, in writing, whether it keeps any spread between what the plan pays and what the pharmacy receives. The answer should cover every dispensing channel and any related company. Also ask the bidder to list all administrative, transaction, clinical program, and other fees. A pricing model is only transparent when every dollar has a clear path. 3. Can We See and Confirm the Net Cost of Each Drug? A large rebate does not, by itself, prove that a plan has the lowest cost. Ask each bidder to show the plan’s net cost after rebates, discounts, fees, and other credits. Require drug-level reporting and request a sample report during the RFP process. Then ask how those numbers can be tested after implementation. This helps the evaluation team compare what the plan is expected to spend, not just the size of a rebate guarantee. 4. What Can Change During the Contract? A strong proposal should explain whether the PBM can change its maximum allowable cost lists, pharmacy network, formulary, pricing rules, specialty drug list, or fees during the contract. Ask which changes require notice and which require the plan sponsor’s approval. For maximum allowable cost pricing, request a clear appeal process, response deadlines, and access to the data supporting the change. The contract should also state the plan’s options when a change causes higher costs or disrupts member care. 5. Are All Terms and Payments Clearly Defined? Words such as “rebate,” “ingredient cost,” “specialty drug,” “pass-through,” and “fee” can mean different things across proposals. Require plain definitions and make sure the same definitions appear in the final contract. The RFP should also ask brokers and consultants to disclose all direct and indirect compensation tied to the pharmacy benefit. For plans covered by the Employee Retirement Income Security Act, federal rules require certain brokerage and consulting compensation disclosures before a service arrangement is entered into, renewed, or extended. How an RFP Should Work. A PBM RFP should do more than identify a winning bidder. It should create the framework for the contract, reporting, and ongoing performance reviews. Clear questions make proposals easier to compare and reduce surprises later. Before selecting a partner, confirm that every important promise can be measured, verified, and enforced. Sources: https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-69 https://www.dol.gov/newsroom/releases/ebsa/ebsa20211230

Why Specialty Drugs Matter Prescription drug costs have been rising for years. Specialty drugs are one of the biggest reasons why. These medications are often used to treat complex, long-term, or rare health conditions. They can be very important for the people who need them. But they can also be very expensive. In many cases, there may not be a lower-cost generic option. Sometimes a biosimilar may be available, but not always. That creates a tough challenge for plan sponsors. They want members to get the right medication. They also need to manage costs so the health plan stays strong. The Challenge for Plan Sponsors A small number of specialty drug claims can drive a large share of total pharmacy spend. That means one high-cost medication can have a big impact on the plan. Plan sponsors may have several options. They can pay the full cost. They can look for lower-cost alternatives. They can consider biosimilars when appropriate. They can also use assistance programs, copay support, or other funding tools. Another option is international pharmacy sourcing for select brand medications. How Saving EDGE SMART Delivery – International Works ProCare Rx offers this option through Saving EDGE SMART Delivery – International. This is a home-delivery mail order program that helps eligible members receive refills of select high-cost brand medications through international pharmacy partners at a lower cost. The program focuses on eligible maintenance medications. These are medications a person takes on a regular basis. Sourcing may include countries such as New Zealand, Australia, Canada, and the United Kingdom. Canadian-only sourcing is also available by request. Members who participate must acknowledge and follow Food and Drug Administration guidance for personal use of imported medicine. A Careful Review Comes First This is not an experimental drug program. Eligible medications are reviewed by pharmacists before they are used through the program. The review includes the medication strength, dose, form, quantity, and other details. If the name, packaging, or tablet looks different because it comes from another country, that information is clearly explained to the member. The goal is to lower cost while keeping the member’s medication experience clear and safe. What the Savings Can Look Like In one representative sample from a client pool, seven specialty medications had a total cost of $69,391.29 before the program. Through Saving EDGE SMART Delivery – International, the total cost was $12,853.74. That created savings of $56,537.55, or 81.48 percent. Across the sample, savings ranged from about 45 percent to 95 percent, depending on the medication. Specialty drug costs are not going away. But with the right strategy, plan sponsors can reduce costs while helping members stay on the medications they need, and ProCare Rx is here to guide the conversation. Sources: ProCare Rx Case Study https://www.iqvia.com/newsroom/2024/01/global-medicine-spending https://www.fda.gov/industry/import-basics/personal-importation

For years, pharmacy benefit data has largely lived behind closed doors. Employers receive reports. Consultants review trends. Vendors summarize performance. But the people ultimately responsible for managing pharmacy spend and improving member outcomes are often left reacting to information instead of truly understanding it. That is beginning to change. As pharmacy costs continue to rise, benefits leaders are facing increasing pressure to answer difficult questions. Why are costs climbing? Which medications are driving spend? Are members using medications appropriately? Are plan strategies actually working? While pharmacy plans generate enormous amounts of it, the challenge is accessibility and usability. Static Reporting Is No Longer Enough Most reporting systems were built to deliver static snapshots. They provide information after the fact, often in the form of spreadsheets or quarterly reports that require interpretation before action can even begin. By the time the data reaches decision-makers, the opportunity to intervene may already be gone. That is why platforms like Zero!n are becoming increasingly important for modern benefits leaders. Rather than functioning as a traditional reporting tool, platforms like this are designed to create a live, interactive environment where users can explore data in real time. Instead of requesting another report from a vendor or analyst, a benefits leader can ask questions directly within the platform and immediately see the answers unfold across the entire dataset. For example, if an employer wants to understand the impact of anti-obesity medications on their plan, they can isolate that category and instantly see how it affects utilization, plan pay, member costs, prescribing patterns, and long-term trends. One selection updates the entire system. Every chart, graph, and metric adjusts dynamically. That level of visibility matters because pharmacy management has become far more complex than simply monitoring total spend. Why Real-Time Visibility Matters Today’s plans must balance cost, access, clinical efficacy, member experience, and long-term outcomes simultaneously. They must identify utilization trends early, monitor specialty drug exposure, evaluate generic dispensing opportunities, and understand how prescribing behaviors influence overall plan performance. Without access to actionable data, most organizations are left making decisions with only partial visibility. Interactive analytics platforms also help shift the conversation from reactive to proactive. Instead of discovering problems months later through a retrospective report, benefits leaders can identify emerging patterns as they develop, including: Sudden spikes in utilization Concentrated spend within a specific therapeutic class Shifts in member behavior Changes in prescribing patterns Growing exposure to high-cost specialty medications These insights become visible sooner, allowing organizations to intervene earlier and more strategically. Equally important is the ability to tailor insights to different audiences. Executives may need high-level dashboards focused on PMPM trends and overall plan performance, while clinical teams may require deeper visibility into member profiles, utilization patterns, or formulary adherence. Flexible platforms allow both perspectives to exist within the same ecosystem. Turning Data Into Better Decisions There is also a growing recognition that transparency alone is no longer enough. Simply handing over raw data does not create clarity. Benefits leaders need tools that help them interpret, segment, and operationalize information in ways that support real decision-making. In many ways, the future of pharmacy benefit management will belong to organizations that can turn data into action faster than everyone else. The plans that succeed will not necessarily be the ones with the most information. They will be the ones that can understand what their information is actually telling them—and act on it with confidence.

ProCare Rx Named Gold Stevie ® Award Winner in the 2026 American Business Awards ®

Pharmacy costs can feel unpredictable. One year it’s specialty drugs. The next, it’s GLP-1s. Then it’s a new wave of therapies that seem to hit plans all at once. But when you step back, there’s a different story. There is a level of predictability in today’s pharmacy market. The challenge is not that change is happening. It’s understanding what is driving it—and what employers should do next. Demand Isn’t Just Growing. It’s Being Created. We’re seeing a clear shift in how drugs are brought to market. Manufacturers are building direct relationships with consumers. Through advertising, digital channels, and new access models, they are creating stronger connections with patients than ever before. That connection matters. It creates “stickiness.” When a member asks their doctor for a specific drug by name, that demand is no longer passive. It is intentional. And it often leads to higher-cost therapies entering the plan. For employers, this means pharmacy trend is not just about utilization. It is about influence. Understanding that shift is the first step in managing it. GLP-1s Are the Prototype for What Comes Next The rise of GLP-1 medications has made this trend impossible to ignore. But it is not just about weight loss drugs. GLP-1s have opened the door to something bigger: direct-to-consumer access models that sit outside of traditional pathways. In many cases, manufacturers are experimenting with how they connect, distribute, and price their products. This creates a new dynamic. It raises real questions about the future of rebate-driven models. It introduces alternative ways to access medications. And it provides a blueprint that could extend into other therapeutic classes. For plan sponsors, this is not a one-off event. It is an early signal of broader change. The Role of the PBM Is Evolving As the market shifts, so does the role of the PBM. There will always be a need for core data, claims insight, and the ability to guide members to the most appropriate and cost-effective options. That foundation is not going away. But how value is delivered is changing. The traditional focus on rebate administration is giving way to something more direct and more immediate. Employers are starting to look beyond delayed rebates and toward upfront savings. For example, if a plan can access a drug at a 50% discount through a direct channel, that can be more impactful than waiting six to nine months for a 30–35% rebate on the same product. This is a different way of thinking. It prioritizes real-time savings, transparency, and flexibility over legacy structures. What This Means for Employers The pharmacy landscape is not becoming more chaotic. It is becoming more intentional. Manufacturers are shaping demand. New access models are emerging. And the economics behind drug pricing are shifting in real time. For employers, the opportunity is to respond just as intentionally. That means: Looking beyond traditional rebate structures Exploring alternative sourcing and direct programs Using data to guide decisions, not just report on them Prioritizing member engagement as part of the strategy This is where forward-thinking PBM partners are focusing their efforts. At ProCare Rx, the goal is simple: help employers think beyond the status quo. That means evaluating new options as they emerge, staying flexible in how coverage is structured, and using data and engagement to drive better outcomes because without a doubt, the market will keep evolving. Source: John Drakulich during his panel at YOU Powered

Smoke and Mirrors: Why Reporting Still Falls Short in Pharmacy Benefits, and What to Do About It

In early 2026, Congress passed sweeping pharmacy benefit manager reform as part of the federal budget package. While the law includes several provisions, two stand out for employers and benefits leaders:  Mandatory 100% rebate pass-through New detailed reporting requirements These changes are designed to bring more transparency and alignment to how pharmacy benefits are managed. For employers, they create both opportunity and responsibility. Let’s break down what this means in plain terms. What Is Rebate Pass-Through? When a drug manufacturer pays a rebate, it is usually tied to a drug’s placement on a formulary or overall utilization. Historically, PBMs negotiated these rebates. But the way those dollars flowed back to employer plans was not always clear. Under the new federal law: PBMs must pass through 100% of rebates, fees, and price concessions they receive from drug manufacturers to the health plan. Rebates can no longer be retained as hidden revenue. Payments must be remitted on a regular schedule. In simple terms, the rebate dollars tied to your plan must now go back to your plan. Why This Matters Rebates have long been one of the most misunderstood parts of pharmacy benefit management. Employers often saw a rebate check but had limited visibility into: The total rebate amount negotiated Any fees retained by the PBM The true net cost of the drug after all concessions Full pass-through changes the incentive structure. Instead of revenue being tied to rebate retention, compensation shifts toward clearly defined service fees. That is a significant structural change. What About the New Reporting Requirements? The second major reform is transparency. PBMs must now provide employer health plans with detailed reporting that includes: Gross drug spend vs. net drug spend Total rebates, discounts, and fees received Spread pricing information Member out-of-pocket cost data Reports must be provided at least semiannually, and in some cases quarterly upon request. For plan sponsors who take their fiduciary responsibilities seriously, this is a big development. Why Reporting Changes Everything Data changes conversations. With more standardized reporting, benefits leaders can better answer key questions: Are we paying a fair net price? Is our PBM’s compensation aligned with our goals? Are member out-of-pocket costs improving or rising? Are specialty trends being managed appropriately? Transparency does not automatically lower costs. But it does give employers the tools to evaluate performance in a more objective way. What Employers Should Do Now Although implementation is phased in over several years, benefits leaders should begin preparing now. 1. Review Your Current PBM Contract Understand: How rebates are currently structured Whether you are already on a 100% pass-through model What reporting rights you currently have Not all “transparent” contracts are created equal. 2. Define What Success Looks Like Rebate pass-through is important. But net cost matters more.High rebates do not always equal lower overall spend. The goal should be total cost control, improved outcomes, and better member experience. 3. Prepare to Use the Data Receiving reports is one thing. Knowing how to interpret them is another. Benefits leaders may need: A standardized internal review process Independent analytics support A clearer dashboard that separates gross, net, specialty, and trend data Transparency only works if it is acted upon. The ProCare Rx Perspective At ProCare Rx, transparency has never been a trend. It has been a foundation. Long before federal reform required 100% rebate pass-through and detailed reporting, ProCare Rx built its model around: Clear rebate structures Defined service fees Straightforward net cost reporting Clinical programs that focus on total drug spend, not just rebate volume The goal is simple: align incentives with employer outcomes. Rebates matter. But real pharmacy value is measured by overall cost control, member safety, and thoughtful clinical oversight. As federal reforms roll out over the next several years, employers should not just ask, “Are we compliant?” They should ask, “Are we aligned?” Transparency is no longer optional in this industry. It is the new standard. And for employers who want to lead, not just react, this is an important moment to evaluate whether their PBM model truly supports their long-term strategy. SOURCES: https://www.sidley.com/en/insights/newsupdates/2026/02/congress-passes-significant-federal-pharmacy-benefit-manager-reform-impacting-pharmaceutical-market https://www.mintz.com/insights-cen t er/viewpoints/2146/2026-02-06-congress-passes-landmark-pbm-reform-2026-spending-bill https://hallrender.com/2026/02/05/federal-pbm-reform-is-here-unpacking-key-provisions-of-the-landmark-legislation/ https://www.sentinelgroup.com/resource-center/2026/congress-passes-pbm-reform-caa-2026

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