Buying pharmacy benefits is no longer a routine procurement exercise. For brokers, consultants, CFOs, and HR leaders, PBM oversight now sits squarely in the risk management category. The wrong contract, the wrong data rights, or the wrong internal assumptions can cost a plan millions. Here are six non-negotiables every pharmacy benefits purchaser should demand.
Knowledgeable staff
A prudent process starts with competent people. The fiduciary standard does not require perfection, but it does require informed decision-making. That means the employer, broker, consultant, and internal benefits team must understand how PBMs make money, how to design a pharmacy benefit, how to evaluate clinical management, how specialty drugs are priced, and where conflicts of interest appear.
The “prudent expert” requirement matters. If the plan sponsor does not have that expertise internally, it must hire it. Relying on a PBM to explain whether its own arrangement is fair is not oversight. It is delegation without control.
Vendor contract access
Purchasers need access to vendor contracts, not just summaries, assurances, or sanitized reporting. One reason is international mail order pharmacy arrangements. In some cases, drugs sourced through these channels are marked up by 2,000% or more before being passed through the benefit plan.
That kind of spread does not show up clearly in a typical PBM performance review. It is buried in related-party arrangements, subcontractor agreements, specialty pharmacy terms, or opaque purchasing structures. If the purchaser cannot see the underlying contracts, it cannot verify whether pricing is fair.
Claim data access
Access to complete, usable, plan-level claim data is no longer optional. The Department of Labor and Consolidated Appropriations Act enforcement environment will only put more pressure on plan fiduciaries in 2026 and beyond.
Plan sponsors need data that allows independent review of drug pricing, rebates, fees, specialty claims, formulary decisions, prior authorization outcomes, and pharmacy reimbursement. A PDF summary from the PBM is not enough. Purchasers need raw data rights, audit rights, and the ability to share data with independent advisors working on behalf of the plan.
Medical benefit drug claim oversight
High-cost drugs are not only paid through the pharmacy benefit. Many are billed under the medical benefit through physician offices, hospital outpatient departments, infusion centers, and specialty clinics. These claims may involve J-codes, HCPCS codes, units, modifiers, and provider markups that are difficult to monitor without the right data.
Purchasers should require access to medical drug claim data and an independent review process to evaluate pricing, units billed, site-of-care patterns, duplicate billing, and opportunities to move select drugs to lower-cost channels when appropriate. PBM oversight is incomplete if medical benefit drug spend is ignored.
Fiduciary PBM contract
There is a difference between a fiduciary PBM contract and a contract that uses friendly language like “fiduciary aligned.” Purchasers should not accept branding, slogans, or partial transparency as a substitute for enforceable fiduciary obligations.
A real fiduciary PBM contract should define who the PBM serves, how compensation is earned, what revenue must be disclosed, what must be passed through, and what happens when conflicts arise. If the PBM keeps spread pricing, hidden rebates, data fees, manufacturer payments, pharmacy network revenue, or GPO income, the contract should say so plainly.
Adequate resources
PBM oversight requires independent tools. Do not rely solely on PBM self-reporting. The plan sponsor should have its own resources to validate pricing, benchmark claims, review specialty costs, and test contract performance.
At a minimum, purchasers should have access to an independent AWP price reporting agreement or similar pricing validation resource. Without it, the plan is asking the PBM to grade its own paper.
The larger point is simple: pharmacy benefits purchasers cannot manage what they cannot see, test, or enforce. A fiduciary standard of care demands more than a competitive RFP. It demands evidence, access, expertise, and contractual accountability.
How We Can Work Together
Whether you’re a plan sponsor trying to get control of pharmacy spend, or a broker guiding clients through PBM decisions, education is the fastest way to improve outcomes. If you want a focused, high-value session your team can actually use, here are several ways we can work together.
Option 1: Get Certified
American College of Benefit Specialists (ACoBS) equips benefits professionals with practical knowledge across pharmacy, medical, retirement, and voluntary benefits. Organizations working with ACoBS-certified consultants gain better plan oversight, stronger vendor accountability, and more disciplined cost control. The certification signals a clear commitment to fiduciary guidance and protecting plan assets.
Option 2: Book a Webinar
A clean, educational session for employers, brokers, or TPAs. We’ll cover the most common PBM profit tactics, how to spot contract red flags, and what a fiduciary standard of care looks like in pharmacy benefits. Great for client education and thought leadership.
Option 3: Join the Virtual Roundtable
Bring your internal team (HR, Finance, and Benefits) or your broker group. I’ll lead a live discussion focused on PBM oversight, cost drivers, and what to ask your PBM right now. You’ll leave with a short action list you can use immediately.
Option 4: Get a Quote
Pharmacy benefits now rival medical spend for many plans. Yet most are still governed by contracts few have fully read and pricing models few can clearly explain. That is a fiduciary risk, not just a cost issue.
If you want lower spend, tighter oversight, and alignment you can defend in front of a board or audit committee, act with intent. Certify your team. Educate your clients. Pressure test your PBM.
