🧩 “We Already Have a PBM” Isn’t a Strategy—It’s a Stall Tactic

H Catausan
Jun 18, 2025
3 min read

When employers claim, “We already work with a PBM,” they often mean just that. But that statement doesn't speak to outcomes, accountability, or value. Why? Most PBMs are structured to obscure—not to clarify—what’s really happening behind the scenes.

🔍 The Prism Lens on PBM Oversight

Independent pharmacy consulting firms like The Prism Health Group see this all the time. Their experts emphasize:

“Many PBMs guarantee $X in savings or discount levels—but never meet or exceed those guarantees. Prism…has been instrumental…in holding the PBM to their contractual guarantees…provid[ing] pricing audits and rebate audits”.

That quote isn’t about unique cases—it’s systemic. Prism's audits, like those featured in their “Behind the Curtain: PBM Audits That Actually Find the Crap” webinar, are designed to unearth hidden fees and buried non-compliance.

💡 What Smart Employers Know (But Most Don’t Ask)

Performance guarantees don’t equal performance
PBMs may promise gold—then deliver bronze. Prism’s audit teams regularly uncover unfulfilled guarantees. Those discoveries are not anomalies—they're patterns.
Deep-dive financial and rebate audits are non-negotiable
We recommends annual financial audits every 2–3 years. These reviews are the only way to ensure your PBM isn’t quietly recouping undisclosed margins.
Audit isn’t a one-off; it’s ongoing accountability
Once you uncover gaps, you need processes to enforce correction. Our teams work with employers and brokers to maintain follow-through—and that’s where real savings occur.
Clinical & analytic oversight drives smarter PBM design
Our project team's role goes beyond auditing—they help employers optimize formularies and rebate strategies based on real-world clinical and pricing.

🛠️ The Steps Every CFO & Benefits Leader Must Take

Step	What to Do	Why It Matters
1. Question everything	Ask your PBM for audit rights and performance measure proof. Demand NDC‑level claims transparency and rebate breakdowns.	Without detail-level data, you're flying blind.
2. Conduct proactive audits	Use independent pharmacy consultants to audit pricing, rebates, and contractual compliance.	Audits reveal shortfalls and hidden fees.
3. Reconcile and enforce	Compare audit findings to PBM guarantees and enforce clawbacks where necessary.	Silence signals acceptance—don't let that happen.
4. RFP or reprocure	If your PBM can’t perform, it may be time to switch providers. Structures like pass-through or carve-outs deliver clarity and better alignment with goals.	You deserve a partner, not a profit engine.
5. Track measures consistently	Make audits and performance tracking an annual budget line.	Transparency isn’t optional—it’s table stakes.

🧠 Why It Works: Seeing What Prism Already Knows

From Prism’s thought leadership and webinars:

PBMs routinely “miss” promised savings and rebates.
Reports like “Behind the Curtain…” show how audit strategies cut through smoke and mirrors.
Audits are just the start—the real value lies in enforcing, negotiating, and designing plans backed by hard insights.

🗣️ How Herb at OVD Approaches PBM Accountability

At OVD, we've built this strategy into our core consulting services:

🧾 Claims-level review: Every pharmacy claim is tracked to ensure reimbursed vs. reimbursed accuracy.
🧑‍🤝‍🧑 Bespoke audit partnerships: We team up with independent analysts—like Prism—to validate every guarantee.
🛠️ Plan & PBM recommendation: Based on audit outcomes, we proactively recommend smarter PBM models and contracts.
📈 Continuous oversight model: We don’t just report—we stay on guard, ensuring improvements stick.

🔚 The Bottom Line

“We already work with a PBM” is a convenient conversation-stopper. But let’s be honest—it doesn’t reflect strategy or performance.

If you're not asking tough questions, commissioning audits, and enforcing accountability, you're complicit in the leakage that costs employers millions—and damages employee trust.

➡️ It’s time to flip the script. Instead of letting opacity define outcomes, let's make transparency the rule, not the exception.