PLAN SPONSOR FAQ
The PBM questions plan sponsors actually ask
The questions that keep self-funded decision-makers up at night, answered plainly: how to tell if you are overpaying, your fiduciary exposure, renewal leverage, straight answers from your PBM, and how a broker brings pharmacy depth to clients.
GC
By Ginny Crisp, PharmD · Reviews hundreds of PBM contracts a year
Published July 2026 · Updated July 2026
These are the questions self-funded plan sponsors ask us most, grouped by who is asking. If you own the budget, you want to know whether you are overpaying and whether you are exposed. If you run the benefit, you want straight answers and no surprises for your members. If you advise the plan, you want to bring real pharmacy depth to your clients. The short answers are below, each linked to the tool or guide that goes deeper.
If you own the budget (CFO and Finance)
You are accountable for the number, and the hardest part is that the standard PBM report is built to keep the number unexplained.
How do I know if we are overpaying our PBM, and can I prove it?
You verify net cost against the contract's pricing model and audit the claims, not the PBM's summary report. Overpayment usually hides in spread pricing and narrow rebate definitions that an aggregate report never shows. With claim-level and channel-level audit rights, the gap between what the plan is charged and what the pharmacy is actually paid becomes a measurable number, which turns a suspicion into proof. The free toolkit library has worksheets to run against your own claims.
Why is our pharmacy spend up double digits, and how do I explain it to the board?
Most of the increase lives in places a standard PBM report does not break out: net cost per script by channel, rebate gross-to-net, specialty routing to PBM-owned pharmacies, and high-cost drug mix such as GLP-1 and specialty. A report built to show those drivers turns an unexplained trend into a board-ready explanation. See what we are seeing across plans.
Am I personally exposed to a fiduciary claim over pharmacy benefits?
If you sponsor a self-funded plan you are an ERISA fiduciary for pharmacy spend, and "we trusted our PBM" is not a defense. The protection is a documented, prudent process for selecting, monitoring, and evaluating the PBM, so you can show how decisions were made, not just that a PBM was hired. The fiduciary documentation toolkit turns that into a checklist.
How do I walk into renewal with my own numbers instead of reacting to the PBM's?
The 90 days before renewal decide your leverage, and your PBM started preparing months ago. Pull your claims data, benchmark your pricing against the market, read the actual contract, and set specific priorities before the PBM presents terms, so you negotiate from your analysis rather than their framing.
How do I get a PBM number I can actually verify?
A number is only as trustworthy as the audit right behind it. If you cannot choose the auditor, examine the underlying claims, audit more than once a year, and treat the findings as binding, the report is faith rather than verification. The Contract Language Library shows the audit-rights language that makes a PBM's numbers checkable.
If you run the benefit (HR and Benefits)
You own the member experience and the PBM relationship, and you are the one who hears about it when something breaks.
How do I avoid a member disruption I did not see coming?
Most disruptions trace to a contract clause nobody read, a formulary exclusion, a step-therapy rule, or a mid-year change, rather than a clinical decision. Reading the formulary-management and override clauses before renewal is how you see the disruption before your members feel it.
Why is it so hard to get a straight answer from our PBM, and what should I ask?
In many contracts the answer is optional because the reporting and disclosure language was written loosely. Specific, contract-anchored questions make the answer mandatory: ask for net cost by channel, the fee behind every invoice line, affiliated-pharmacy claim share, and the data that supports each guarantee. The Contract Language Library has the disclosure language to ask for.
Is our "customized" formulary built for our members or the PBM's rebates?
Ask how your formulary differs from the PBM's standard book of business. Often it does not. The formulary is where rebate economics meet clinical decisions, and whose interest wins that contest decides what your members pay and what your plan spends.
What should I have ready before the PBM presents renewal terms?
Your own claims data, your market benchmarks, and your documented priorities, prepared before the PBM frames the terms. Walking in with your own analysis is the difference between negotiating and accepting what is presented. The contract review readiness checklist lays out the prep.
How do I make a GLP-1 or specialty coverage decision without guessing?
Coverage is a design decision with clinical criteria and contract language, not a simple yes or no on the formulary. Pairing clear clinical criteria with adherence support and tight contract terms is what separates plans that get value from plans that treat it as an on-off switch.
If you advise the plan (Brokers and Consultants)
You own the client relationship, and pharmacy is increasingly where that relationship is won or lost.
How do I bring real pharmacy expertise to my clients without becoming a PBM expert myself?
Bring the contract questions, not just the renewal quote. Prescription Benefit Solutions partners with advisory teams rather than competing with them, so a broker can lead the pharmacy conversation with the right questions and bring in a specialist when a situation calls for one. The toolkit library is built to arm advisors.
How do I see what is really in my client's PBM deal?
The same handful of revenue streams, spread pricing, retained rebates, administrative fees, manufacturer-direct payments, and owned-pharmacy margin, hide on nearly every contract. Knowing where each one sits in the contract is how you surface what the deal actually contains. The guide on what a PBM contract audit examines walks through each one.
About working with an independent auditor
What does an independent PBM audit actually examine?
An independent PBM contract audit reads the pricing model, the rebate definitions, the audit-rights clause, the per-channel net cost, and the termination terms to find where money leaks and where the plan lacks leverage. It checks the contract against what the plan is actually charged, not just the PBM's summary. See the full guide on what a PBM contract audit examines.
How is an independent PBM audit different from a broker-led review?
A broker-led review is part of a broad benefits relationship, while an independent PBM audit is a focused, pharmacy-specialist examination of the contract and the claims. The two are complementary: the strongest outcomes come when the broker leads the relationship and a pharmacy specialist reads the contract line by line alongside them. The side-by-side comparison goes deeper.