ANNUAL AGGREGATE · 2025
What We're Seeing in PBM Contracts
Aggregated patterns from the pharmacy benefit manager contracts Prescription Benefit Solutions reviewed across self-funded employer clients in 2025. No individual client is identified.
GC
By Ginny Crisp, PharmD · Reviews hundreds of PBM contracts a year
Published July 2026 · Updated July 2026
In 2025, Prescription Benefit Solutions reviewed hundreds of pharmacy benefit manager contracts across 203 self-funded employer clients, delivering $78.7 million in contracted savings and averaging roughly $469,000 in contracted savings per pharmacy benefit review client. Results vary by plan.
$78.7M
Contracted savings
203
Self-funded employer clinets
100s
PBM contracts reviewed/year
25%
Average savings on PBM RFPs
We see hundreds of PBM contracts a year. That volume gives us pattern recognition no single employer or broker has. Below are the patterns we saw most consistently across the 2025 contracts we reviewed. These are general market observations, not any one plan's data.
Spread is hidden inside aggregate guarantees
The single most common cost leak we see is spread buried inside an aggregate pricing guarantee. When a contract promises an average discount across all claims rather than a guarantee on every claim, the pharmacy benefit manager can hold the average while charging the plan above contracted rates on individual drugs and keeping the difference. The math reconciles at the portfolio level, so it never shows up on a summary report. Reading the guarantee at the claim level, not the aggregate level, is where the recovery starts. Across our 706 client engagements in 2025, this pattern surfaced more than any other.
Rebate definitions quietly exclude whole revenue categories
Most plans believe they receive 100% of rebates because the contract says so. The leverage sits in the definition of "rebate." When the defined term excludes administrative fees, inflation payments, data-sale revenue, and manufacturer payments routed through an affiliated rebate aggregator, a 100% pass-through of a narrow definition can still leave real manufacturer revenue with the pharmacy benefit manager. We read the definition before we read the percentage. The percentage is the headline; the definition is the contract.
Specialty claims get routed to the PBM's own pharmacy
Specialty drugs are where the dollars concentrate, and specialty routing is where we see margin concentrate too. Contracts increasingly require, or quietly default, that specialty fills go through a pharmacy the pharmacy benefit manager owns. That vertical arrangement lets the same company set the price, dispense the drug, and report on its own performance. A plan that cannot route specialty elsewhere has lost its strongest pricing lever on its highest-cost claims. We look for the language that forces the routing, and the language that would let a plan keep its options open.
Audit-rights windows are written too narrow to use
Audit rights look standard on the page and turn out to be unusable in practice. We repeatedly see windows capped at a short look-back period, limited to a handful of claims, restricted to the pharmacy benefit manager's own auditor, or gated behind advance-notice and confidentiality terms that make a real audit impractical. By the time a plan suspects a problem, the window to examine the claims that would prove it has often already closed. An audit right you cannot exercise on a meaningful sample of claims is not really a right. This is the provision we push hardest to widen.
Copay accumulator and maximizer economics are rarely fully disclosed
Copay accumulator and maximizer programs are tools we use in client work, and in many plans they genuinely help. Whether they help a specific plan depends on design, disclosure, and the contract terms underneath, and those terms are rarely volunteered. What we check is the economics: the vendor's fee structure, including percentage-of-savings and per-fill fees, who actually keeps each captured assistance dollar, whether reclassification mechanics were executed with informed plan sponsor sign-off, and how the "savings" the vendor reports are defined and by whom. We also read the member-communication plan, because a well-designed program communicated badly lands on HR as surprise-bill escalations. A program can be right for the plan and still be wrapped in terms that give away most of its value. We read for who keeps each dollar.
Biosimilar formulary placement still favors the higher-cost option
Biosimilars are on the market and should be lowering plan spend, yet formulary placement often steers utilization back toward the higher-cost reference product or the version that carries the richer rebate. The contract may permit biosimilars without preferring them, and a permission without a preference rarely moves utilization. We check whether the formulary actually rewards the lower-net-cost biosimilar or simply allows it to exist alongside the option that pays the pharmacy benefit manager more.
How 2025 broke down
Across 706 client engagements in 2025, the work that surfaced the largest dollars per client was the pharmacy benefit review and the PBM market analysis. Pharmacy benefit reviews averaged roughly $469,000 in contracted savings per client; PBM RFP engagements averaged roughly $562,000 in contracted savings per client, at an average savings rate of 25%. Contracted figures, not guaranteed outcomes.
132
Pharmacy benefit reviews
86
Contract review engagements
59
PBM RFP engagements
429
Other engagements
Contract language gets read in nearly every engagement type: every pharmacy benefit review starts from the client's PBM contract, and every RFP means reading multiple bidders' proposed contracts, which is how the contracts we review each year run well past the engagements formally scoped as contract reviews.
Engagement categories sum to 706 total 2025 client engagements. PBR = Pharmacy Benefit Review. RFP = PBM Market Analysis. Results vary by plan; savings figures are contracted, not guaranteed.