Your PBM Is Your Health Plan’s Blind Spot
Cut pharmacy costs 30% and you cut total plan costs about 10%.
Here’s why we recommend auditing the most conflicted, most overpaid, least examined entity in your benefits plan:
Pharmacy audits regularly uncover PBMs charging plans $80–$100 for drugs they paid the pharmacy $15–$25 for. Your report shows only what you paid, and the contract lets the PBM keep the difference.
Keep your broker. Keep your PBM.
Self-insured with 100 or more employees?
Who sets your price?
NADAC is a public benchmark of what pharmacies pay for drugs. Your PBM bills from its own price list.
Express Scripts’ parent owns Quallent, a generic drug label. Researchers at 46brooklyn found its list prices averaged about 38 times wholesale cost, and one generic launched roughly 7,000% above the cheapest competitor.
A discount off a price your PBM sets is no discount.
✔ Is your guarantee a discount off list price? Then ask who set the list price.
An average discount hides overpriced drugs.
A “generic effective rate” averages discounts across all generics. Your PBM meets the guarantee while overcharging for the drugs your employees take most. This makes your big, promoted discount irrelevant.
Pricing guarantees often cover less than three-quarters of plan spending because specialty drugs, compounds, vaccines and diabetic supplies are often excluded.
✔ Does your contract price your top 25 generics by name?
“100% of rebates,” after their cut.
Manufacturer rebates often pass through an aggregator owned by the PBM’s parent, which takes its cut first. Admin fees and inflation payments fall outside the rebate definition.
You receive 100% of what remains.
Meeting your rebate guarantee proves the PBM paid the promised minimum—not that it passed through everything it collected.
✔ Does your contract cover every manufacturer payment, whichever affiliate receives it?
Their pharmacy, their profit.
Specialty classifications, mail-order incentives and automatic refills steer prescriptions to pharmacies the PBM owns.
The FTC found those pharmacies generated $7.3 billion above estimated acquisition cost on specialty generics from 2017 to 2022.
Measure mail-order savings by net cost, claim by claim, not the discount. Automatic fills members never requested add to your bill.
✔ How much of your spending goes to PBM-owned pharmacies?
Add up every fee.
The admin fee leaves out clinical program, reporting, network and implementation fees. Your plan often pays a higher dispensing fee than the pharmacy receives, and the PBM keeps that difference too.
✔ Does your PBM disclose every fee in one total?
Who keeps recovered overpayments?
Your PBM recovers overpayments from pharmacies on claims your plan funded. Your contract determines whether that money comes back to you.
✔ Does your contract return every recovery to your plan?
The PBM grades its own work.
Many contracts let the PBM approve your auditor, select the claims and exclude rebate records.
✔ Can you choose your auditor and give them access to all claims and rebate records?
DCI checks your contract against your claims.
DCI’s pharmacists review your agreement and 12 months of claims. You see what your plan paid, what the pharmacy received and what the PBM kept, along with the savings amount and the contract changes needed.
Didn’t Congress fix this?
The new federal rebate requirements begin January 1, 2029, for calendar-year plans. Your contract renews before then.
When does your contract renew automatically—and what’s the deadline to stop it?
Let's Talk
At DCI Solutions, we help companies take a more strategic approach to savings.
If you’d like to learn more about how DCI can help your company, we’re happy to have a conversation.
Please feel free to contact us here: info@dcisolutions.net | 760-809-8734 or set up a meeting here .
