We restructure or replace your PBM contract to require acquisition-cost pricing, 100% rebate pass-through, audit rights, and contractually defined definitions — closing the three loopholes that let traditional PBMs convert your formulary into a margin product.
Pharmacy is the single category where carrier-side margin is most opaque. We focus narrowly on contract structure, formulary governance, and the audit rights that make those terms enforceable.
We replace AWP-minus pricing with NADAC- or invoice-based acquisition-cost pricing where available. AWP is a published list price that the pharmacy never pays; pricing off it is a margin construct, not a cost construct.
The PBM contract specifies 100% rebate pass-through to the plan, with reconciliation timelines (90 days from receipt), audit rights (30 business days, on-site), and a recoupment formula if reconciliation is late. The contract defines 'rebate' inclusively to capture admin fees, GPO fees, and inflation rebates.
Maximum Allowable Cost lists are the PBM's primary spread instrument. We contractually require the right to audit the MAC list, compare it to NADAC, and recoup overpayments. Spread pricing is prohibited by contract — not by good faith.
Specialty drugs are 2% of scripts and 50%+ of pharmacy spend. We evaluate carve-out to a specialty-only vendor, copay-assistance program coordination, and site-of-care steering where clinically appropriate. Patient access is the constraint.
Quoted in writing in Schedule A. Includes contract diagnostic, RFP, and rebate reconciliation. Zero PBM-paid compensation.
The corresponding 408(b)(2) compensation disclosure is published at /legal/408b2 and refreshed quarterly.
Two minutes to scope the engagement. One business day to a calendared 30-minute call with a principal. No carrier in the room. Engagement letter follows in writing.