Home / PBM 101 / PBM 101 Checklist

Your PBM Evaluator Checklist

Check what your PBM can prove, not just promise

Navitus has been operating on a fully transparent model
for more than 20 years, long before the rest of the industry began catching up. We know what transparency looks like when it’s real and not just a marketing term.

To help you spot the difference, we’ve built a practical checklist you can use to test whether your PBM is transparent or just claims to be.

PBM Fundamentals

PBM 101 e-book

Glossary

In today’s health care landscape, transparency is having a moment.

Rising pharmacy costs and growing regulatory scrutiny are forcing plans to demand a clear view of what they’re actually paying for. So suddenly every other pharmacy benefit manager (PBM) claims to be transparent, and almost no one defines it.

But here’s the problem: even when PBMs claim transparency, most plans still don’t get clear answers to basic questions, such as where the money goes, who gets paid and what drives the spend. 
That’s why evaluation matters. A transparent PBM partner should be able to answer those questions without turning the process into a scavenger hunt. 

So how can you tell whether a PBM is truly transparent or just saying it? Start by using our checklist below.

a clear choice

How Transparent is Your PBM?

Think you have a clear understanding of what it means to operate with complete transparency? See how your current PBM stacks up against some of our core requirements for financial and operational transparency:

Revenue Sources

  • Does your PBM generate zero spread revenue on pharmacy or manufacturer claims?
  • Does your plan immediately benefit and receive 100% of all network and pharma contract improvements?
  • Does your plan receive 100% pass through of all rebates and discounts, including any upside or increased savings through the contract?
  • Are 100% of all pharmacy costs passed back to your plan (in retail, mail and specialty channels)?
  • Is formulary product selection based on a lowest-net-cost philosophy (not focused on higher costs to get more rebates)?

Contract Definitions

  • Does your PBM use independent, publicly verified third-party definitions for brands and generics?
  • For generics, is a single MAC list applied across all distribution channels?
  • Is your PBM contract free of any incentives that benefit the PBM from the relationship between plan sponsor, PBM and patient?
  • Do your utilization management (UM) programs have appropriate prior authorization (PA) approvals and step therapy used to manage cost, not generate revenue for PBM?

Access to Data

  • Do you have access to your data at any time with the same data sets used for auditing or financial guarantee true-ups?
  • Do you have access to all claims data down to the NDC-11 level?
  • Do you have access to all MAC lists used and clarity to how and when they’ll be used?

Contract Transparency

  • For three-year contracts (or longer), are plan admin costs the same for each year and are they known up-front (rather than a contract where year two and three costs escalate after year one)?
  • Do you have complete control over all aspects of your pharmacy benefit, including network/distribution channels and formulary?
  • Do you have the ability to terminate the contract without cause after the first year and keep your rebates?
  • Do you have unrestricted access to pharmaceutical manufacturer and pharmacy contracts?

Auditing

  • Do you have access to review and audit all documents and data pertaining to your benefit program?
  • Do you have access to view and audit all network pharmacy arrangements?
  • Do you have access to actual and total claim files for audit purposes (rather than separate and partial claim files)?
  • Do you have access to actual net claim files for audit purposes including all claim calculations?
  • Do you have access to view and audit all manufacturer contracts?

If you or your PBM can’t answer these questions, it may be time for a change. Reach out to us to see how a transparent model can drive better results.  

Contact Us

PBM Insights

Interested in exploring more PBM insights? 

Check out our PBM 101 resource page for straight answers, helpful guides and practical tools that help you make sense of the complicated PBM world.

Visit the PBM 101 Hub
Get to Know the PBM Pass-through Model

Get to Know the PBM Pass-through Model

In the world of pharmacy benefit management (PBM), there are multiple models a company can follow, including the pass-through, hybrid and traditional models. While all PBMs negotiate discounts and rebates with manufacturers on behalf of their clients,…

Read More about Get to Know the PBM Pass-through Model
previous arrow
next arrow
Portal Login