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Rebates Aren’t Savings: Debunking the Most Misunderstood Term in Pharmacy Benefits

Rebates Aren’t Savings: Debunking the Most Misunderstood Term in Pharmacy Benefits

by | Nov 26, 2025 | Pharmacy Benefit

In the world of pharmacy benefits, the term “rebate” often gets bandied about as though it’s synonymous with savings. But in many cases, what looks like savings is not what it seems. We believe it’s time to pull back the curtain on rebates, explain their long-term impact, and highlight why our transparent, fiduciary model makes all the difference.

 

The Pharmacy Rebate “Shell Game”

When a drug manufacturer brings a product to market, a list price is established. A portion of that list price may later be given back to the payer via a “rebate” negotiated through the pharmacy benefit manager (PBM). This sounds straightforward: you pay a high price, you negotiate a rebate later, and you net a lower price. But in practice, the flow of money is complex, opaque, and often misaligned with the interests of the plan sponsor or the members.

For example:

  • A classic PBM model may negotiate rebates and keep a portion of that rebate as profit rather than passing 100 % through to the employer or plan.
  • The size of the rebate is often tied to the list price rather than the net effective cost or clinical value. Some drugs with high list prices generate large rebates, which may make them financially attractive to a PBM, even if those drugs are not the best value for the plan or the patient.
  • Because the rebate is paid after the fact, the plan or employer may still have paid or been exposed to the full list price upfront and borne the risk of that higher cost.

 

In short, rebates can become part of a shell game; the terminology makes it sound like you saved money, but unless the structure is transparent and aligned to your interests, you may not realize the benefit you expect.

 

The Long-Term Impact of Pharmacy Rebate Models

The misalignment created by rebate-centric models has several long‐term implications for employers, plan sponsors, and members:

Higher list prices – Because rebates are tied to list price, manufacturers have an incentive to set or maintain high list prices to generate larger rebate potential. PBMs may favor drugs with big rebates because their revenue depends in part on chasing those rebates. Analysts have flagged how this “chase the rebate” incentive can drive drug prices.

Formulary distortions – If drug placement on a formulary is influenced by rebate size rather than clinical value or lowest net cost, plans may end up covering higher‐cost alternatives. That means increased employer spend and possibly higher out-of-pocket costs or less-optimal therapy for the member.

Incentivized high-cost utilization – When plan sponsors or advisors use traditional “rebate spreadsheets” to compare PBMs and focus on the highest rebate guarantees, they unintentionally reinforce this dynamic. Choosing a PBM based on the largest rebate promise means the PBM must manage utilization toward the highest-cost drugs, since those are the products that generate the largest rebate checks. Over time, this approach not only distorts formulary design but also entrenches high-cost utilization patterns that inflate overall spend and undermine true savings.

Delayed benefit to the plan sponsor – Because rebates are retrospective, there is a lag time, and in some models, the plan sponsor may never clearly see or receive the full rebate value or understand how it was retained or split.

Transparency and fiduciary risk – Plan sponsors have fiduciary responsibilities (especially for self-funded plans under ERISA). When rebates, fees, dispensing profits, and other revenue streams are opaque, the plan may be at risk of hidden costs or conflicts of interest.

Unsustainable cost curves – If the model encourages high list prices and large rebates, the baseline cost of drugs grows, putting long‐term pressure on premiums, benefit design, member cost share, and employer budgets.

In essence, when rebates are treated as a “win” without drilling into the mechanics, you may be celebrating a gain while missing underlying structural issues that will catch up later.

 

How US-Rx Care’s Transparent Model Fixes the Problem

US-Rx Care’s model is built around transparency, alignment, and long‐term value. Here’s how we ensure rebates aren’t hiding costs, but instead support cost-effective outcomes:

  • Fiduciary alignment and flat fee contracting: We operate as a fiduciary PBM; our model is structured so that the plan sponsor’s interests come first. We don’t retain hidden rebates or manipulate margins to our advantage.
  • No conflicts of interest: Unlike traditional PBM models that may have opaque revenue flows, our contract is built on the principle of no hidden profits, no spread pricing, no rebate retention, just aligned savings.
  • Clinical-driven formulary and utilization design: We don’t let rebate size drive decisions; we let clinical value, efficacy, and net cost drive decisions.
  • Full transparency in reporting:  Plans get auditable, clear reporting so they know exactly what they’re paying, what’s being reimbursed, and how savings are flowing.
  • Sustainable savings: Because we fix the misaligned incentive structure, we don’t just push short-term gains; we build models that control drug spend in the long run, protect against inflationary pricing, and align member care with cost value.

 

For employer groups, health plans, and benefits advisors, this means a model where the word “rebate” is no longer the source of confusion or hidden costs, but simply one part of a clearly defined value chain.

 

Key takeaways for Benefits Advisors and Plan Sponsors

Rebates don’t always equal savings. They often mask higher costs and misaligned incentives. Plan sponsors should dig deeper by asking who keeps the rebate, how list prices are affected, and whether rebate structures truly align with their fiduciary duty.

Transparency is the key to real cost control. PBM contracts should clearly define what revenue the PBM retains and how savings are passed through. Focus on net cost, not gross price minus rebate, and evaluate whether drug choices are driven by clinical value or rebate size. In the long run, rebate-heavy models inflate prices and erode savings. A transparent, fiduciary-aligned PBM ensures every dollar saved genuinely benefits the plan and its members.

 

A Better Way Forward: Pharmacy Transparency That Delivers Real Savings

If you’re tired of rebate gimmicks, hidden markups, and opaque PBM models, it’s time for a refresh. Let’s talk about how US-Rx Care’s fiduciary-based, transparent pharmacy benefit model can help you eliminate waste, control costs, and improve member outcomes without sacrificing care. Connect with us today at usrxcare.com/contact.

Large PBMs Balk at Push to Reduce Drug Prices

by | Nov 19, 2019 | PBM, Pharmacy Benefit

In a move that exemplifies the potential conflict of interest that some large pharmacy benefit managers have, the nation’s largest PBM earlier this year said it would demand that rebates remain unchanged when drug makers roll out new price cuts.

Drug makers earlier in the year said they would start reducing prices as well as the rebates they pay PBMs to appease lawmakers and the Trump administration, saying it would reduce the cost of medicine for patients.  

But not long after the announcement, the nation’s largest PBM, United Healthcare, fired off a letter to drug companies telling them that if they planned to reduce prices and rebates they would have to give seven quarters of notice (that’s 21 months if you’re counting) when they intend to lower prices.

The letter, which was confirmed in news reports in the health care trade press, highlights what many critics say is an inherent conflict of interest among some of the large PBMs operating in the country.

Some background

When PBMs first came on the market, the services they offered were processing pharmacy claims and negotiating discounts on medications for the health insurance companies with which they contracted.

Later though, they found a new way to make money: rebates. They would approach two manufacturers that made similar versions of a drug and play them off against each other to elicit the largest rebate they could. Whichever one offered the larger rebate would have their pharmaceutical placed on the drug plan’s formulary.

The problem is that these large PBMs do not pass on the full rebate to their clients, like health insurance companies and health plan enrollees. Instead, they keep most of the rebate for themselves. As a result, PBMs with this business model are not motivated to include the lowest-priced drug on their formulary, but rather the one for which they can receive the largest rebate check.

The latest

United Healthcare sent out the letter to drug makers after pharmaceutical manufacturer Sanofi S.A. said it would cut the price of its cholesterol-lowering drug Praluent by 60%. It did so after its competitor Amgen Inc. reduced the price of its cholesterol drug Repatha by the same amount.

United Healthcare’s demand that drug companies give 21 months’ notice when they plan to reduce prices has caught many drug makers off guard, since many of them have been looking to cut prices as pressure mounts on the industry from Washington.

The dominance of United Healthcare’s PBM OptumRX and its competitor Express Scripts means that group health plan enrollees are often left at their mercy, as many large health insurers have contracts with them.

If a drug company does not give the rebate that a large PBM demands, it could lose access to patients – and patients lose access to that drug. The only way to play the game is to offer a larger rebate and increase prices, which in turn increases the prices that patients have to pay.

Fortunately, there are a number of smaller PBMs in the marketplace that have different business models that take payers’ needs into consideration and aim to reduce the out-of-pocket costs for patients. They contract with employers and insurers directly to make this happen.

National Educational Conference 2019

by | Sep 4, 2019 | Pharmacy Benefit

The Self-Insurance Institute of America’s National Educational Conference is right around the corner and we hope to see you in San Francisco 9/30 – 10/2.

Please contact Mark Mincy at mmincy@us-rxcare.com to schedule a meeting to discuss how we can save your clients up to 50% in pharmacy spend without changing Benefits (or PBMs).