Transparency Isn't Enough: Design, Alignment, and Execution Deliver the Savings

Transparent pricing has become the baseline. But the reality is that true transparency and full pass-through pricing are far from standard practice. Many pharmacy benefits managers (PBMs) are still applying spread pricing at retail, and most don’t pass through all of the manufacturer value they capture. So even when a proposal uses the language of transparency, it often stops well short of the real thing. And here’s the uncomfortable truth: none of it tells you whether the vendor will actually lower your client’s pharmacy spend.
Transparency is necessary. However, it isn’t sufficient. A pass-through contract provides better visibility into plan economics, but does not necessarily lead to more favorable plan costs. Two PBMs with identical pricing structures can deliver wildly different outcomes. What separates them isn’t disclosure. It’s their ability to execute – to identify waste, act to remove it, and show sustainable results.

Here are the four key areas to evaluate next:

1. Clinical Management is the Real Differentiator

Start with GLP-1s, because they’ve quietly become one of the fastest-growing lines on your clients’ pharmacy statements. Spending on this category rose more than 500% between 2018 and 2023. If a vendor can’t clearly describe how it manages GLP-1s, including coverage criteria, indication verification, and continuation requirements, it can’t manage your client’s most explosive cost driver. That single answer tells you a lot about everything else.
The broader principle behind GLP-1 management applies across the whole plan. Fewer than 2% of prescription claims often account for more than half of total pharmacy spend. A single specialty drug can add over $250,000 a year to plan costs. That’s where savings live, and where automated rule-checking quietly fails.
Automated systems match claims against preset rules and leave the most expensive decisions unreviewed. Independent, pharmacist-led clinical management does the opposite. It identifies the person behind the high-cost claim, verifies medical necessity, and steers toward clinically equivalent, lower-cost alternatives before the plan pays a dollar.

Ask these direct questions:
  • Are your pharmacists assigned to proactively review high-cost claims, or do they only respond to prior authorization submissions?
  • When a prior authorization comes in, does a clinician review it, or does an automated system?
  • What’s your documented GLP-1 strategy, including coverage criteria, indication verification, and continuation requirements?

2. Formulary Design: Lowest Net Cost, Not Rebate Chasing

Here’s an assumption worth challenging: a bigger rebate doesn’t mean a lower cost. A drug with a smaller rebate and a lower list price often costs the plan less than one with a large rebate sitting on top of an inflated list price. Net price is what matters.

Watch how the formulary gets built. A formulary designed for lowest net cost favors the drugs that cost your client least after rebates, generics, and biosimilars. A rebate-driven formulary steers members toward high list-price drugs that pay the vendor more. That difference is the whole game.

The principle is simple: lowest net cost, not the largest rebate.

3. Modular Programs and Channel Optimization

Not every plan needs the same tools. Look for optional cost-containment programs your client can add where they create clear economic value, rather than a fixed bundle that forces one approach on every population.

Channel strategy is where some of the largest per-claim savings hide. Directing members to the right dispensing channel, alternative specialty channels, manufacturer copay assistance, and mail order when appropriate can meaningfully cut spend.

Ask for numbers, not descriptions:

  • What percentage of your clients’ specialty spend flows through alternative channels?
  • What’s your manufacturer copay assistance enrollment completion rate?
  • How do you update channel recommendations when pricing or eligibility changes?
If a vendor can describe the capability but won’t show you the results, that tells you something.

4. Implementation, Service, and Auditability

Most client frustration doesn’t come from pricing. It comes from service and transition failures: late or incorrect ID cards, claims rejections at cutover, and specialty members who lose continuity of therapy. These problems are predictable, which means good vendors have named owners and documented protocols to prevent them.

Service durability matters just as much. Uneven account management relationships inhibit the trust that is so critical to effective plan management. Ask how many clients each account manager supports, what the team’s average tenure is, and whether the vendor brings recommendations proactively or only when asked.

Then test auditability. Contract audit rights aren’t the same as usable audit access. A strong vendor can run a live, claim-level audit during your evaluation, showing ingredient cost, dispensing fees, and rebates on demand. If they can’t demonstrate it now, they don’t have it.

From Insight to Action

Everything here points to one capability: controlling waste before it reaches the pharmacy benefits plan. Data access is a starting point, not a strategy. What matters is whether a vendor moves from insight to action, identifying the opportunity, recommending a specific intervention, getting approval, implementing it, and tracking realized savings against projections.

Transparency only gives you visibility. Independent, pharmacist-led clinical management, especially in categories like GLP-1s, controls unnecessary spend. Lowest net cost execution, across formulary and channel, captures the savings. Auditability proves it all held up.

The next phase of this market won’t be defined by who discloses pricing. It’ll be defined by who can prove true savings, audit it, and act on identifying and rectifying additional opportunities at scale. Evaluate for that, and you can make a recommendation with confidence.

For a practical framework to evaluate transparent PBMs that actually drive results, download the latest RxBenefits Market Report here. Illuminate Rx is an affiliate of RxBenefits, the country’s first and leading pharmacy benefits optimizer.