Before Choosing a Transparent PBM, Employers Should Ask These 10 Questions

US-Rx Care urges employers and benefits providers to use contract-level tests covering fiduciary responsibility, conflicts of interest, pricing, audit rights, and data ownership as employers look beyond PBM transparency claims.

TAMARAC, Fla., Sept. 21, 2026 /PRNewswire/ -- Employer pharmacy costs are rising faster than healthcare costs overall. Business Group on Health estimates drug costs will increase 12% in 2026, compared with an 8.5% increase in total healthcare costs, while pharmacy already accounts for roughly one-quarter of employers' healthcare spending. "Changing pharmacy benefit managers (PBMs) does not mean changing the incentives behind the arrangement," said Renzo Luzzatti, CEO of US-Rx Care, the nation's first fiduciary pharmacy risk manager and industry leader since 2007. "Employers still need to understand how the PBM makes money and whether its financial interests may be misaligned with the interests of the plan."

In a previous Business Group on Health survey, 41% of employers said they were either changing PBMs or conducting a PBM request for proposals. As employers look for alternatives, they are entering a market where transparent, pass-through models make similar promises without accepting the same contractual obligations.

The Contract Can Be Scored

US-Rx Care recently evaluated PBM agreements using the Nautilus Contract X-Ray, an independent contract analysis tool that scores 10 provisions across three areas:

• Fiduciary Conduct: PBM obligations and incentives aligned with the interests of the plan and its participants.
• Financial Integrity: Clear, verifiable economics across pricing, rebates, and fees.
• Oversight and Control: Employer rights and flexibility to monitor, manage, and exit the relationship.

The 10 contract provisions translate into practical questions employers can use to evaluate a PBM agreement, including:

• Fiduciary Loyalty Commitment: Does the contract recognize the plan sponsor's fiduciary and oversight responsibilities?
• Pass-Through Pricing Integrity: Are manufacturer payments and other sources of value passed through to the plan?
• Rebate & Manufacturer Revenue: Are rebates and related payments fully defined and disclosed?
• Data Ownership & Rights: Does the employer own and retain unrestricted access to its claims data?
• Audit Rights & Verification: Can the employer independently audit pricing, rebates, compensation, and contract performance?
• Conflict of Interest & Network Neutrality: Does the PBM avoid steering prescriptions toward affiliated pharmacies or other entities for its own financial benefit?
• Carve-Out & Vendor Rights: Can the employer use other pharmacy or clinical solutions without punitive pricing or restrictions?
• Lowest Net Cost & Clinical: Are formulary and clinical decisions designed around the lowest net cost among appropriate therapies?
• Termination & Clean Exit: Can the employer terminate or transition to another PBM without contractual barriers that make changing vendors impractical?
• Administrative Fee Transparency: Are administrative fees complete, itemized, and predictable?

Transparency and Fiduciary Alignment Are Different Tests

Luzzatti cautioned against treating disclosure and fiduciary alignment as interchangeable. A PBM may provide extensive data access or avoid some traditional vertical integration conflicts, but those features alone do not require it to act in the interests of the plan. Fiduciary alignment goes further: the PBM accepts a contractual obligation to act in the best interests of the plan and its participants.

"In one recent contract reviewed through the third-party framework, 10 of 10 measures were rated fail or concern with an overall score of 29 out of 100," Luzzatti said. "The largest gaps involving rebate administration and pharmacy network pricing."

Taken together, those provisions test whether fiduciary alignment, verifiable economics, and employer control are built into the agreement, from how the PBM is compensated and audited to who controls data, clinical decisions, and vendor relationships. By comparison, US-Rx Care's contract scored close to 100%.

From Transparency Claims to Verifiable Alignment

A contract-level standard gives employers and consultants a consistent way to compare PBMs beyond pricing and financial guarantees to drive the selection process. The goal is to verify that each vendor's proclaimed business model is reflected in their service agreement.

The primary threshold remains whether the PBM will contractually accept fiduciary obligations defined under the Employee Retirement Income Security Act (ERISA), including duties to act in the interests of the plan and its participants without any conflict of interest. This gives employers a legally defined standard in full alignment with their own legal obligation as plan fiduciary.

"A label such as transparency is a marketing claim. A contract is an obligation," Luzzatti said. "Employers should look into the contract to confirm if the PBM accepts full fiduciary responsibility for the services or abdicates any fiduciary responsibility, which should be a red flag for the plan."

About US-Rx Care
US-Rx Care is revolutionizing America's pharmacy benefits system by replacing opaque, profit-driven PBMs with a transparent, fiduciary model that puts employers and members first. Founded in 2007, the company combines clinical rigor, ethical contracting, and data-driven oversight to cut drug costs by up to 50% or more while also improving health outcomes. Operating under a legally binding ERISA fiduciary standard, US-Rx Care eliminates conflicts of interest, passes through 100% of manufacturer rebates and pharmacy discounts, and delivers measurable savings without compromising care. Privately owned and free from outside financial influence, US-Rx Care is setting the new standard for pharmacy benefit management—restoring trust, accountability, and real control for employers, benefits consultants, and health plans nationwide. Website: www.us-rxcare.com

References:

• Business Group on Health. (2025, August 19). Business Group on Health survey: 9% health care cost increase for 2026. businessgrouphealth.org/newsroom/news-and-press-releases/press-releases/2026-employer-health-care-strategy-survey
• Business Group on Health. (2025, December 2). Trends to watch in 2026. businessgrouphealth.org/resources/trends-to-watch-in-2026

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SOURCE US-Rx