Exposing the Hidden Costs: A Four-Part Series on Pharmacy Benefit Fraud, Waste, and Abuse It’s easy to assume that a medical degree signals trustworthy intent. But when you’re footing the bill for a pharmacy benefit plan, blind trust is expensive. Some prescribers don't just treat patients. They also treat themselves to a slice of your pharmacy spend. When Prescribing Becomes a Profit Center Let’s get this out of the way: most physicians act with integrity. But “most” doesn’t cover your risk. Physician-driven FWA often hides in plain sight and can take many forms: Unnecessary brand prescribing: Choosing high-cost brand-name drugs when a clinically equivalent generic is available.Off-label prescribing of specialty medications: Using drugs outside of FDA-approved indications, often encouraged by aggressive pharma reps or financial arrangements with specialty pharmacies.Script mills: Prescribers linked to telehealth or compounding pharmacy operations that churn out high-cost, low-value scripts for the same handful of drugs.Financial entanglements: Kickbacks, referral fees, or ownership stakes in pharmacies create a direct conflict of interest that drives wasteful prescribing.Therapy changes based on DTC influence: Some prescribers switch patients to expensive medications simply because the patient saw a TV commercial or social media ad, even when the current therapy, or a lower-cost alternative, is clinically sound and cost-effective. And all of it is being billed to your plan. Credentials Don’t Equal Clinical Prudence The white coat carries weight. But that credibility can be weaponized. A prescription from a licensed MD looks authoritative to patients and even PBMs. Yet if no one is looking behind the script pad, plan sponsors can be left paying for treatments that lack clinical justification or economic sense. It’s not just about medical integrity. It is about financial discipline. That is something plan sponsors can’t afford to assume is baked into every prescription. A Fiduciary Lens: Auditing Prescribers Like You Audit Claims Your duty as a plan sponsor isn't just to trust. It is to verify. That means: Prescriber-level audits: Identify outlier physicians whose prescribing patterns deviate from clinical norms.Utilization controls: Flag suspect behaviors like excessive use of certain drug classes or unusual prescribing volumes.Tighter prior authorization policies: Especially for high-cost brands or specialty meds, ensure there's a legitimate medical need before plan dollars are spent. These controls aren't punitive. They are protective of your plan assets, your fiduciary responsibilities, and your members’ health. Look Past the Lab Coat Fraud, waste, and abuse don’t always look like fraud. Sometimes they look like “care.” But when prescribing decisions are driven by economics or marketing instead of evidence, the plan and the patient lose. Don't just audit claims. Audit intent. If you're not scrutinizing prescribers, you're not protecting your plan. Reach out to TransparentRx to learn how prescriber-level oversight can stop financial leakage before it starts. Elevate your expertise in pharmacy benefits management with the Certified Pharmacy Benefits Specialist® (CPBS) program, sponsored by the UNC-Chapel Hill Eshelman School of Pharmacy. Whether you're an HR leader, finance executive, consultant, or pharmacist, this certification provides the in-depth knowledge and strategic insight…

Exposing the Hidden Costs: A Four-Part Series on Pharmacy Benefit Fraud, Waste, and Abuse Most employees use their pharmacy benefit correctly, but a small group exploits loopholes. Their actions inflate drug spend, strain plan reserves, and jeopardize the fiduciary duty employers owe to every participant. Keep reading to learn how to identify and prevent patient-driven pharmacy fraud. Spotting the Tactics Prescription or doctor shopping is the classic red flag. A member visits several prescribers (primary care, urgent care clinics, and telehealth services) without disclosing prior fills. The goal is to obtain overlapping scripts for controlled substances, high-demand GLP-1s, or brand-name drugs that should have been substituted. Pharmacy hopping follows the same playbook on the dispensing end. Instead of returning to the same network pharmacy, the member fills each claim at a different location and hopes no single pharmacist sees the refill pattern. Because claims adjudicate cleanly in real time, the abuse can continue until analytics catch it. Card sharing and identity fraud surface when a friend or relative presents another member’s ID at the counter or online portal. Claims history no longer aligns with the true patient, which skews drug-to-drug interaction checks and safety edits. Resale or diversion of high-cost therapies often involves hepatitis C antivirals, weight-loss injectables, or oncology support drugs. After shipment, the member sells unused doses through gray-market channels or returns them for cash. Plan dollars fund inventory that never benefits the covered population. Manipulating prior authorization takes two forms. Some members look for prescribers known to write non-preferred brands on thin clinical justification. Others flood the appeals desk with emotional narratives rather than clinical evidence or push HR and leadership to override a denial. Both moves bypass the formulary’s intent and erode fairness for every participant. Why It Matters Patient-Driven Pharmacy Fraud Poses Significant Risks Prevention Playbook Real-time claims edits reject duplicate prescribers, early refills, or conflicting therapies and route exceptions to a clinical pharmacist the same day.Refill and quantity limits keep new starts on 30-day supplies and require partial fills for high-risk drugs until adherence and safety are confirmed.Lock-in programs assign confirmed abusers to one prescriber and one pharmacy. The written notice cites patient safety and fiduciary duty as the rationale.Hard PA stops with third-party review require an independent clinician to sign off before any override. Every approval is documented with medical evidence, not anecdotes.Pattern-recognition analytics flag members who visit multiple pharmacies or providers, repeatedly reversing or returning claims for high-cost specialty drugs, or sit in the top one percentile for spend. Quarterly reviews feed case management and compliance teams.Member and provider education puts PA rules and formulary logic front and center in welcome kits, open-enrollment webinars, and provider newsletters.Zero-tolerance language in the plan document states that benefit misuse triggers investigation and possible disciplinary action, including removal from coverage or legal escalation. How to Identify and Prevent Patient-Driven Pharmacy Fraud Fraud prevention is not about punishment; it is about stewardship. When plan administrators insist on accurate prescribing, transparent appeals, and data-driven oversight, everyone wins when…

Exposing the Hidden Costs: A Four-Part Series on Pharmacy Benefit Fraud, Waste, and Abuse Not all pharmacy benefit waste is driven by PBMs or patients. And for larger self-funded employers or public entities, unmonitored pharmacy claims can quietly drain seven figures from the budget over time. In some cases, this can exceed $2 million in avoidable waste, depending on the scale and structure of the plan. Sometimes, it’s coming straight from the dispensing counter. Whether it’s a neighborhood retail pharmacy, a compounding operation, or a specialty outlet working behind a white-glove reputation, pharmacy-driven fraud, waste, and abuse (FWA) is very real and very expensive. The worst part? Most of it looks legitimate on the surface. If you're relying on clean adjudication reports or vendor-provided summaries to spot problems, you're missing the real story. Pharmacy-Driven FWA: What It Looks Like Let’s be clear: many pharmacies operate ethically. But the bad actors, and even the opportunistic ones, exploit the blind spots in your oversight structure. Here’s how: 1. Overdispensing and Auto-Refills Some pharmacies routinely refill medications without member requests, even when adherence or clinical need doesn’t support it. The result: stockpiled drugs, increased cost, and unnecessary waste. These refills are often masked as "member convenience," but they’re really just revenue padding. 2. Compounded Medication Abuse Compound pharmacies have become creative billing engines, stacking high-cost ingredients into topical creams and pain gels that offer little to no added therapeutic benefit. These compounds often bypass formulary controls and rack up thousands per script—usually without clear documentation or peer-reviewed justification. 3. Upcharging and Repackaging Some pharmacies, including mail-order, game the system by billing for higher-priced NDCs (National Drug Codes) that represent the same drug in different packaging. For example, a 30-day supply of a generic might have five different NDCs, with wildly different reimbursement rates. Guess which one they pick? 4. Split Billing and Code Stacking Split billing is the tactic of breaking apart a prescription into multiple claim lines to maximize reimbursement especially in specialty or infusion pharmacy settings. It's technical, hard to detect, and completely unnecessary from a care perspective. Code stacking is a billing practice where a provider or in the pharmacy context, often a specialty or infusion pharmacy, breaks up a service or product into multiple billing codes to maximize reimbursement, even when a single bundled code would be more appropriate. In pharmacy benefits, code stacking can look like: Billing each ingredient of a compounded medication separately, rather than as a bundled compound claim.Submitting multiple procedure codes (often J-codes under the medical benefit) for a single therapy session, such as a biologic infusion.Separately billing for ancillary services like mixing, administration, and drug waste disposal when those costs should already be included in the primary service fee. Why it’s a problem: It inflates claim costs artificially, driving up plan spend without delivering any additional value.It bypasses utilization controls that may be in place for bundled services or therapies.It can expose plan sponsors to compliance and audit risks, especially if the billing crosses…

Exposing the Hidden Costs: A Four-Part Series on Pharmacy Benefit Fraud, Waste, and Abuse If you’re a plan sponsor still looking at fraud, waste, and abuse (FWA) through the lens of member misuse or doctor shopping, you’re only seeing the surface. The most damaging form of FWA, in pharmacy benefits today isn’t being driven by patients, prescribers, or even pharmacies. It’s baked into your non-fiduciary PBM contract. When the gatekeeper is the problem, the entire system breaks. When Misaligned Incentives Become a Business Model Most employers assume their PBM partner is working on their behalf. After all, they’re the ones “managing” your plan. But when your PBM profits more when you spend more, that’s not plan management. It’s margin extraction. This is FWA at the structural level. Five Ways Non-Fiduciary PBMs Exploit the System (and Your Budget) 1. Spread Pricing The PBM bills your plan $120 for a generic drug and pays the pharmacy $6. That $114 spread? It stays with the PBM. Multiply that across millions of claims and you start to understand why this is a preferred revenue stream. Unless your contract explicitly bans it, it’s happening. 2. Rebate Chasing Non-fiduciary PBMs often favor high-rebate drugs even when lower-cost alternatives are clinically equal or superior. Why? Because they retain a portion of the rebate, often undisclosed, and build formularies to maximize rebate revenue, not member outcomes or net cost efficiency. 3. Specialty and Mail-Order Steering PBMs own pharmacies and they profit by steering members toward their own dispensing channels, often for drugs with low clinical value. These internal referrals frequently bypass lower-cost, clinically appropriate alternatives, increasing plan costs and leaving members to pay more out of pocket for medications that offer little added benefit. 4. Vague Contract Terms “Pass-through pricing,” “rebates,” and “guarantees” sound good until you realize none of those terms are precisely defined. Loopholes allow PBMs to reclassify revenue, exclude certain drugs, or apply creative accounting to reduce what gets passed through. 5. Data Obstruction If you don’t have full visibility into claims-level data, including the amount paid to the dispensing pharmacy, you’re operating blind. And that’s exactly how your non-fiduciary PBM wants it. FWA by Design, Not Mistake This isn’t accidental. It’s not a bad actor. It’s a system that’s been carefully engineered to enrich PBMs under the radar of plan sponsors. Many employers don’t even realize they’re being taken for a ride until an audit uncovers millions in avoidable spend. And even then, most plans settle for minor corrections instead of a total structural reset. How to Fight Back Demand a fiduciary-standard contract: Clear terms. No spread. 100% rebate pass-through. Auditable.Control the formulary: Don't allow a non-fiduciary PBM choose your drug list without scrutiny.Build in oversight: Require monthly reporting and quarterly audits, not just vague performance guarantees.Benchmark everything: Ingredient costs, dispensing fees, and rebates down to the claim level. Bottom Line PBM-driven FWA isn’t a footnote. It’s the headline. If you don’t fix this first, you’re just rearranging deck chairs on the Titanic. Coming…

SCOTUS declines to hear PBM case and other news from around the interweb: Get Certified Now! SCOTUS declines to hear PBM case. The Supreme Court declined Monday to consider an appellate court’s 2023 decision overturning portions of an Oklahoma law regulating pharmacy benefit managers, raising questions about the implications for state actions to rein in the companies’ business practices. The 10th Circuit appeals court ruled that federal laws regulating private employer-sponsored health plans and Medicare’s drug benefit preempt the 2019 state law’s provisions that aimed to bolster independent pharmacies’ bargaining power with PBMs, which help negotiate retail drug prices between drugmakers and payers. Community pharmacies have long panned the middlemen — which are responsible for 80 percent of the market — for steering customers toward pharmacy chains they own. CMS head urges PBMs to end drug rebates. CMS chief Mehmet Oz, MD, is calling on the nation’s largest pharmacy benefit managers to voluntarily abandon the current drug rebate model, or risk its elimination by the government, Bloomberg reported June 24. “There’s a possibility that we have a window now where three big PBMs might actually consider doing away with the rebate/kickback system,” Dr. Oz said. The remarks signal that the Trump administration may revive attempts to eliminate the payments drugmakers send to pharmacy benefit managers after prescriptions are filled. FTC Issues Warning on Rebates That Block Lower-Cost Drugs. The Federal Trade Commission (FTC) has issued a policy statement outlining its approach to regulating pharmaceutical rebates and fees under Section 5 of the FTC Act. The statement, released on June 8, 2025, focuses on practices that allegedly harm competition in the prescription drug market. Specifically, the FTC highlights concern over rebate agreements and fee structures between pharmaceutical manufacturers and pharmacy benefit managers (PBMs), which it claims may unfairly exclude competitors or restrict access to lower-cost drugs. How to Create an AI Foundation for Your Benefits Strategy. Employers want to use artificial intelligence-driven analytics to drive up benefits engagement but need the right foundation in place to generate these insights. One in two employers believe that acting on analytical insights will lead to improved employee performance and engagement. It’s therefore unsurprising that employers across the globe are now planning to use AI (artificial intelligence) to generate these insights. More than eight out of 10 (85%) HR professionals plan to use AI in relation to their employee benefits over the next year. The overall goal is to understand their people and tailor employee benefits, communications, and experiences to drive up benefits engagement. Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care. If you're ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter,…

CMS head urges PBMs to end drug rebates and other news from around the interweb: Get Certified Now! CMS head urges PBMs to end drug rebates. CMS chief Mehmet Oz, MD, is calling on the nation’s largest pharmacy benefit managers to voluntarily abandon the current drug rebate model, or risk its elimination by the government, Bloomberg reported June 24. “There’s a possibility that we have a window now where three big PBMs might actually consider doing away with the rebate/kickback system,” Dr. Oz said. The remarks signal that the Trump administration may revive attempts to eliminate the payments drugmakers send to pharmacy benefit managers after prescriptions are filled. FTC Issues Warning on Rebates That Block Lower-Cost Drugs. The Federal Trade Commission (FTC) has issued a policy statement outlining its approach to regulating pharmaceutical rebates and fees under Section 5 of the FTC Act. The statement, released on June 8, 2025, focuses on practices that allegedly harm competition in the prescription drug market. Specifically, the FTC highlights concern over rebate agreements and fee structures between pharmaceutical manufacturers and pharmacy benefit managers (PBMs), which it claims may unfairly exclude competitors or restrict access to lower-cost drugs. How to Create an AI Foundation for Your Benefits Strategy. Employers want to use artificial intelligence-driven analytics to drive up benefits engagement but need the right foundation in place to generate these insights. One in two employers believe that acting on analytical insights will lead to improved employee performance and engagement. It’s therefore unsurprising that employers across the globe are now planning to use AI (artificial intelligence) to generate these insights. More than eight out of 10 (85%) HR professionals plan to use AI in relation to their employee benefits over the next year. The overall goal is to understand their people and tailor employee benefits, communications, and experiences to drive up benefits engagement. COA Files Amicus Brief Supporting 340B Rebate Model Appeal, Warning of PBM Takeover and Urging Congressional Action. The brief, filed in the U.S. Court of Appeals for the D.C. Circuit in support of Novartis and Bristol Myers Squibb in the case Novartis Pharmaceuticals Corporation v. U.S. Department of Health & Human Services et al., docket number 24-2968, reinforces COA’s call to restore the 340B program to its original purpose – helping patients in need – by exposing and reversing the growing financial exploitation of the program by pharmacy benefit managers (PBMs) and hospital systems. Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care. If you're ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

That $99 Spirit Airlines fare grabs your attention. But once you add a carry-on, pick a seat, print a boarding pass, and pay all the extras, you often spend more than you would for the all-in fare at United, for instance. You are packed in with no legroom, nickel-and-dimed the entire way, and left stranded if you need support. Now picture that same approach in pharmacy benefits management. What budget airlines can teach us about PBMs is that low upfront costs don’t guarantee value unless transparency and accountability are built into the model. Non-fiduciary PBMs hook employers with what looks like a low admin fee, such as $4.50 or $6.95 PMPM. Just like with the airlines, the real cost is buried in the fine print: spread pricing, retained rebates, restricted audit rights, and poor clinical oversight. What seemed like a deal ends up costing far more once everything is tallied. Spirit adds more seats to shrink legroom and boost margins. Similarly, non-fiduciary PBMs pad their formularies with high-rebate drugs to increase their revenue, not because these medications work better or cost less for patients. The result is poor patient outcomes and higher total costs. When you ask for transparency or try to audit where the dollars go, you hit a wall. Plan sponsors pay the PBM twice: once for the actual cost of the drugs and again as a separate fee to manage the pharmacy benefit. At TransparentRx, our management fee (∽ $14.95 PMPM) is the full fare. It covers everything, including prior authorizations, appeals, utilization management, and cost-containment programs that other PBMs often carve out and mark up. These services are not optional; they impact access, adherence, and total cost of care. We do not upcharge for them or hide them in separate agreements. There are no hidden revenue streams or backdoor profits. Our formularies are built around clinical value and the lowest net cost, not the size of a rebate check. Every dollar saved goes back to the plan sponsor. We put that in writing, under a fiduciary standard. Low-cost marketing does not mean low total cost. Whether it is flying or pharmacy benefits, if the price looks too good to be true, check the cargo hold. There is almost always something hiding in there. Elevate your expertise in pharmacy benefits management with the Certified Pharmacy Benefits Specialist® (CPBS) program, sponsored by the UNC-Chapel Hill Eshelman School of Pharmacy. Whether you're an HR leader, finance executive, consultant, or pharmacist, this certification provides the in-depth knowledge and strategic insight needed to manage pharmacy benefits with confidence and cost efficiency. Gain up to twenty continuing education credits, enhance your career prospects, and help your organization take control of pharmacy spend. Register today to join a growing network of professionals shaping the future of pharmacy benefits management. Learn more at the Pharmacy Benefit Institute of America.

Selecting a pharmacy benefit manager isn't about choosing the vendor with the most rebates or slickest presentation. It's about making a defensible, fiduciary-grade decision based on transparency, alignment, and timing discipline. Below is the perfect timetable for PBM RFPs, with practical checkpoints to avoid costly mistakes. At a Glance: PBM RFP Timeline January to March: Design the Process with Purpose The first quarter is where leverage is built. Draft the RFP with clear, measurable requirements tied to financial and operational accountability.Select invitees based on performance and transparency. Decide whether to include the incumbent.Require full disclosure from consultants and vendors on all PBM relationships and revenue streams. This is a baseline requirement for fiduciary oversight.Clarify objectives early. The end goal is auditability and alignment with the plan's financial interests, not just the appearance of savings. Rushing this setup invites downstream failure. Plans that skip or delay this step often end up renegotiating under pressure or settling for status quo. April to May: Distribute with Discipline This stage is about enforcement. Release the RFP and allow a minimum of three weeks for responses.Avoid Excel-based distribution. Use a secure RFP platform to reduce version confusion, data loss, and exposure risks.Require structured responses that bind the PBM to disclosed pricing, service guarantees, and contractual terms. Firms that resist or withhold key information are self-selecting out. Let them. June to July: Evaluate and Extract Now the focus shifts to assessment and leverage. Score only what can be verified. Eliminate vendors who offer soft promises with no contractual commitment.Prioritize fiduciary alignment. Vendors that operate on radical transparency, pass-through pricing, and contract clarity should move forward.Conduct interviews with purpose. These are not meet-and-greets. They are working sessions to confirm commitments and gain pricing or service concessions.Select semi-finalists. Selections are based on binding contract terms and pricing not vague claims or verbal assurances. If it's not in writing, it doesn't count. This is where most plans get swayed by presentations or legacy comfort. Don't lose leverage. Keep the process objective. August: Finalize and Sign This is the decision point. Select the winning PBM based on documented commitments, not who talked the best game.Execute the agreement immediately. All terms should already be finalized through prior documentation rounds. If your advisor is still negotiating at this point, the process was mishandled. A PBM should never be chosen before their contract terms are locked in writing. September to December: Transition with Precision This phase ensures readiness by go-live. Refine plan design. Adjust formularies, prior authorization rules, and benefit carve-ins or carve-outs.Test system integration. Ensure eligibility feeds, accumulator syncing, and claims adjudication are working as intended.Prepare member communication. This includes ID cards, digital tools, benefit summaries, and support resources.Launch open enrollment with full confidence in operational execution. Waiting until the fourth quarter to begin implementation planning puts the entire program at risk. The Takeaway A PBM RFP is not a paperwork exercise. It is a financial event with significant implications for cost control, member outcomes, and fiduciary liability. The perfect timetable is…

FTC Issues Warning on Rebates That Block Lower-Cost Drugs and other news from around the interweb: Get Certified Now! FTC Issues Warning on Rebates That Block Lower-Cost Drugs. The Federal Trade Commission (FTC) has issued a policy statement outlining its approach to regulating pharmaceutical rebates and fees under Section 5 of the FTC Act. The statement, released on June 8, 2025, focuses on practices that allegedly harm competition in the prescription drug market. Specifically, the FTC highlights concern over rebate agreements and fee structures between pharmaceutical manufacturers and pharmacy benefit managers (PBMs), which it claims may unfairly exclude competitors or restrict access to lower-cost drugs. Recalibrating employee benefits: How companies are delivering value in a cost-constrained world. As employers head further into 2025, one message is clear: the old rules of employee benefits are fundamentally changing. With rising costs, economic instability, and employees demanding more support and personalization, organizations must transform how they think about benefits. Yet, this isn't a story of increased budgets and ever-increasing programs. Instead, it's a story of smarter spending, sharper focus and using benefits as a strategic tool to drive engagement, retention, and purpose. How to Create an AI Foundation for Your Benefits Strategy. Employers want to use artificial intelligence-driven analytics to drive up benefits engagement but need the right foundation in place to generate these insights. One in two employers believe that acting on analytical insights will lead to improved employee performance and engagement. It’s therefore unsurprising that employers across the globe are now planning to use AI (artificial intelligence) to generate these insights. More than eight out of 10 (85%) HR professionals plan to use AI in relation to their employee benefits over the next year. The overall goal is to understand their people and tailor employee benefits, communications, and experiences to drive up benefits engagement. 83% of Americans Unwilling to Pay More Than $100 for GLP-1s, Survey Shows. While Americans understand the benefits of GLP-1 agonist medications, 83% of Americans are unwilling to pay more than $100 in monthly health insurance premiums for them, even if they were covered, according to the results of the recent KPMG American Perspectives Survey. Willingness to pay differed across age groups. Gen Z was the most likely to pay at 27%, followed by 21% of Millennials, 14% of Gen X and just 6% of Baby Boomers, indicating a generational divide. Why TransparentRx Is Your Trusted Partner for Smarter Pharmacy Benefits At TransparentRx, we specialize in delivering fiduciary pharmacy benefit management services that prioritize transparency, cost containment, and optimal patient outcomes. Our unique approach helps self-funded employers, benefits consultants, and health plan sponsors navigate the complexities of pharmacy benefits while reducing costs and enhancing care. If you're ready to take control of your pharmacy benefit strategy and eliminate hidden fees, contact TransparentRx today for a consultation. Let us help you achieve smarter, more effective benefits management.

Most HR departments don’t have a pharmacy benefit team. They rely on brokers or health plan reps to manage the PBM, rarely dig into pharmacy-specific metrics, and assume someone else is watching the details. But pharmacy benefits are where the real complexity and often the greatest waste lives. If you’re in HR and pharmacy benefits are buried in your broader health plan workflow, this is your opportunity. A small, focused team or even just the right external partners can unlock savings, improve member outcomes, and give your plan the transparency it deserves. Here’s how smart HR leaders are making it happen. Start With a Fiduciary Mindset Pharmacy benefits shouldn’t be managed as just another health plan line item. Most PBMs operate on a profit model that rewards opacity and misalignment. The only way around that is to establish fiduciary-level oversight, acting solely in the best interest of your plan and its members. Even if you don’t have internal pharmacy experts, you can adopt a fiduciary mindset by bringing in partners who work exclusively for you. That means no commissions, no hidden fees, and no loyalty to anyone but your plan. The Roles That Matter Most You don’t need a new department. But you do need someone thinking about pharmacy every day. That might mean reallocating responsibilities within HR or outsourcing to fiduciary-aligned consultants. These are the core roles worth investing in: Pharmacy Benefit Strategist Brings experience from inside the PBM world. Knows what to ask, what to audit, and how to negotiate terms that actually protect your plan.Contract and Procurement Lead Reviews PBM contracts with a fine-tooth comb. Looks for soft guarantees, ambiguous language, and misaligned incentives.Data Analyst or Actuarial Support Translates raw claims into clear insights. Helps model new benefit designs, forecast impact, and identify cost drivers.Clinical Oversight (Pharmacist or Consultant) Ensures utilization management is rooted in evidence, not just cost-shifting. Essential for specialty, GLP-1s, and PA protocols.Project Manager or Implementation Lead Keeps audits, vendor changes, and benefit updates on track. Without this role, good strategy gets stuck in limbo. Strengthen Your Oversight to Get More from Your PBM Relationship Your PBM plays a critical role in managing drug costs, access, and outcomes. Like any complex vendor relationship, the more engaged and informed your team is, the better results you will see. A dedicated pharmacy benefit team allows HR to become an active participant in decision-making rather than just a recipient of updates. This improves the PBM partnership by bringing more clarity, better communication, and shared accountability. When your team is prepared to review data, manage contracts, and provide clinical insight, it creates the structure for a stronger partnership. Your PBM can focus on delivering value, while your team ensures that value aligns with your plan’s goals. It's not about stepping on toes. It's about stepping up. Build Audit and Oversight Into Your Routine Oversight isn’t just an annual rebate check. A good pharmacy benefit team will regularly review: Rebate guarantees and actual pass-throughFormulary changes and exclusionsPrior authorization outcomesSpecialty…