Top 10 Discovery Questions for PBM Evaluation

Choosing a pharmacy benefit manager shouldn't feel like decoding a mystery. Yet most organizations sign contracts without asking the right questions—questions that reveal how their PBM actually operates and where their dollars truly go.

If you're evaluating a PBM partnership, these ten questions cut through industry complexity and get straight to what matters: Full Disclosure, contractual accountability, and alignment with your organization's goals.

#1: Can your PBM show you the exact spread between what they pay pharmacies and what you are billed?

This question addresses spread pricing—a practice where PBMs charge clients more than they pay pharmacies and pocket the difference. Without contractual guarantees of 100% pricing pass-through, you're operating blind. The Fiduciary and The Fully Disclosed PBM® model eliminates spread pricing entirely through contractual commitments to pass-through pricing.

#2: Are you contractually guaranteed to receive 100% of rebates and manufacturer incentives?

Some PBMs retain a portion of rebates or reclassify them to avoid passing them through. Your contract should explicitly state that 100% of all rebates, administrative fees from manufacturers, and other incentives flow directly to you. If the contract includes language like "substantially all" or "eligible rebates," you're not getting everything.

#3: Is your formulary optimized for lowest-net-cost or for highest rebates?

This reveals whether your PBM prioritizes clinical outcomes and your bottom line, or their own revenue. Rebate-driven formularies place high-rebate medications in preferred positions even when lower-cost alternatives exist. Ask your PBM to explain their formulary methodology and provide examples.

#4: Does your PBM help members access copay assistance, patient assistance programs, 340B pricing, or international sourcing?

This question exposes whether your PBM views Member Service as a genuine commitment or an afterthought. Many PBMs create barriers to these savings programs because they reduce prescription volume or interfere with rebate arrangements. A fiduciary approach means actively helping members access every available resource to reduce costs.

#5: If your PBM makes an error or takes unearned revenue, are they contractually bound as a fiduciary to correct it?

Traditional PBM contracts often include language limiting liability and allowing the PBM to keep funds even when mistakes are identified. A Fiduciary PBM is contractually and ethically bound to act in your best interests, which includes correcting errors and returning any unearned revenue. Review your contract for fiduciary language.

#6: Who owns your pharmacy claims data—you or the PBM—and can you access it freely and completely?

Some PBMs claim ownership of this data or charge fees for access. You should own your data and have complete, unrestricted access to it at any time, at no additional cost. This includes member-level detail, not just aggregated reports.

#7: Does your PBM own or financially benefit from a pharmacy or related entity that could influence pricing?

Vertical integration creates inherent conflicts. When your PBM owns mail-order pharmacies, specialty pharmacies, or retail chains, they have financial incentive to direct prescriptions to their own entities—regardless of whether that serves your members best. Ask directly about ownership structures and financial relationships.

#8: Is your formulary managed independently based on clinical evidence alone, or is it influenced by rebates or ownership structures?

Formulary decisions should be made by clinical experts evaluating efficacy, safety, and cost—not by business teams maximizing rebate revenue or steering prescriptions to owned entities. Request details on who makes formulary decisions, what criteria they use, and how they handle situations where clinical best practice conflicts with financial arrangements.

#9: Is your PBM owned by private equity or venture capital firms whose primary goal is increasing profit margins?

Private equity ownership often drives aggressive profit extraction. PE-backed PBMs may prioritize short-term margin expansion over long-term client relationships, leading to practices that inflate costs or reduce service quality. Understanding ownership structure helps you assess whether your PBM's incentives align with yours.

#10: Does your PBM receive any revenue from sources you cannot audit, such as group purchasing organization arrangements or data monetization?

If your PBM participates in opaque revenue arrangements—selling your prescription data, receiving fees from GPOs, or monetizing your claims information—they're profiting from your benefits in ways you cannot see or control. Insist on Full Disclosure of all revenue sources.

The Right Questions Lead to the Right Partner

These questions aren't meant to create conflict. They're designed to establish clarity. When you ask them during your evaluation, pay attention to how prospective partners respond.

At DisclosedRx, we welcome these questions because our entire model is built on Full Disclosure. As The Fully Disclosed PBM®, we operate with one administrative fee and two revenue streams: that admin fee and a shared-savings model where clients keep 75% of all savings we generate. Everything else—every rebate, every discount, every penny of pricing—passes through to you.