What Every Benefits Advisor Should Ask Their PBM
When it comes to pharmacy benefit management, not all PBMs are created equal. Many traditional PBMs rely on opaque pricing models, hidden rebates, and misaligned incentives that can drive costs up instead of bringing them down. For benefits consultants, asking the right questions up front is key to ensuring transparency and delivering measurable savings.
Below is a checklist of essential questions every benefits consultant should ask a prospective PBM, along with red flags and differentiators to look for.
How is your pricing structured?
Why it matters: Traditional PBMs often profit from spread pricing and rebate arrangements that aren’t in the client’s best interest.
Red flag: If the PBM avoids explaining how they make money, chances are the incentives are misaligned.
What to look for: A pass-through pricing model with full transparency. At US-Rx Care, we don’t profit from rebates; we align savings directly with the plan sponsor.
Can you guarantee clinical savings, not just discounts?
Why it matters: Discounts sound good, but they don’t always translate into lower net costs. Without effective clinical management, “discounted” drugs are only solving for one piece of the puzzle.
Red flag: A PBM that only talks about discounts without showing outcomes data.
What to look for: Evidence-based clinical oversight that ensures patients are on the right drug at the right time, preventing unnecessary spend.
How do you handle specialty medications?
Why it matters: Specialty drugs represent less than 2% of prescriptions but more than 50% of drug spend. This is where PBMs often inflate margins.
Red flag: Limited transparency around specialty sourcing and pricing.
What to look for: Programs that ensure clinical appropriateness and offer alternative sourcing strategies. US-Rx Care consistently delivers significant savings on specialty medications without reducing access or quality.
What level of transparency do you provide?
Why it matters: A PBM should be a partner, not a unknown variable. Without visibility, consultants and plan sponsors can’t validate true performance.
Red flag: Reporting that’s overly complicated or excludes certain fees, rebates, or data.
What to look for: Full transparency in contracts, reporting, and outcomes. US-Rx Care provides clear, auditable reports so consultants can demonstrate value with confidence.
How do you align with fiduciary responsibility?
Why it matters: Plan sponsors have a fiduciary duty to act in the best interest of their members. A PBM that prioritizes its own profits puts employers at risk.
Red flag: Any PBM that claims savings but can’t demonstrate alignment with ERISA requirements.
What to look for: Fiduciary-focused solutions that ensure plan sponsors meet their obligations. US-Rx Care contracts are built to protect both the plan and its members.
Key Takeaway for Consultants
A PBM should work for the client, keeping their best interests, and those of the members, at the forefront. By asking these critical questions, benefits consultants can uncover red flags and position themselves as trusted advisors who deliver real value.
We’ve built our model around transparency, fiduciary alignment, and clinically driven savings. The result? Lower costs, better outcomes, and confidence that your PBM is truly on your side.
Discover how US-Rx Care can deliver measurable savings and transparency for you. Connect with us today at usrxcare.com/contact.