RxBenefits has released a new report aimed at benefits advisors and HR leaders evaluating pharmacy benefits managers as regulatory pressure and demand for transparent pricing reshape the market. The report argues that transparent PBM contracts can improve visibility into pharmacy economics, but meaningful savings depend on clinical management, channel strategy, implementation and ongoing service.

RxBenefits is urging employers and benefits advisors to look beyond transparent pricing when evaluating pharmacy benefits managers (PBMs), arguing that visibility into drug costs does not automatically translate into lower spending.

The company has released a report titled How to Evaluate Transparent PBMs with Confidence: A Practical Guide for Benefits Advisors, designed to help benefits consultants and HR leaders assess PBM vendors as federal and state transparency initiatives reshape the pharmacy benefits market.

The report's central argument challenges one of the industry's increasingly common assumptions: transparency is a prerequisite for evaluating pharmacy benefits, but it is not itself a savings strategy.

For self-funded employers, the distinction is important. Transparent or pass-through PBM arrangements can show how money moves through the pharmacy benefits ecosystem, including administrative fees, rebates and other financial components. But greater visibility does not guarantee that the underlying cost of prescriptions will fall.

RxBenefits argues that savings depend on how effectively a PBM manages utilization, high-cost claims, pharmacy channels and the member experience after implementation.

That shifts the evaluation from contract structure to operational performance.

Five Areas for Evaluating PBMs

The RxBenefits report identifies five areas that benefits advisors should examine when comparing PBM vendors: savings execution, clinical depth, channel optimization, implementation quality and service durability.

The framework reflects the increasingly complex role PBMs play in employer-sponsored healthcare. A PBM is not simply negotiating prescription prices. Its responsibilities can include formulary management, pharmacy networks, utilization management, specialty-drug strategies, prior authorization and member support.

The report places particular emphasis on clinical management.

According to RxBenefits, human-led clinical reviews of high-cost claims can uncover savings opportunities that automated systems based solely on predefined rules may miss.

That distinction is becoming more relevant as specialty medicines account for a growing portion of employer pharmacy spending. A small number of high-cost prescriptions can have a disproportionate effect on the overall benefits budget.

RxBenefits cites data showing that fewer than 2% of prescription claims account for more than half of total pharmacy spending. It also points to specialty drugs costing hundreds of thousands of dollars annually as examples of where clinical intervention can have an outsized financial impact.

Specialty Drugs and GLP-1s Raise the Stakes

The economics of pharmacy benefits are increasingly being shaped by high-cost and specialty medications.

GLP-1 drugs provide a prominent example. RxBenefits' report says national spending on GLP-1 medications increased more than 500% between 2018 and 2023.

The category has become a major consideration for employers because medications originally associated primarily with diabetes management have also become widely used for obesity treatment. Their growing utilization creates both potential health benefits and significant financial implications for employer-sponsored plans.

This is where PBM utilization management becomes strategically important.

Employers need to balance cost containment with access to appropriate treatment. A benefits strategy that focuses exclusively on restricting expensive medications could create unintended consequences, while an approach without meaningful utilization controls can expose plans to rapidly escalating costs.

The challenge for PBMs is therefore not simply identifying expensive drugs. It is determining when a high-cost treatment is clinically appropriate, how it should be managed and whether alternative therapies or treatment pathways can deliver comparable outcomes.

Transparency Becomes the Starting Point

Nathan White, chief client officer at RxBenefits, described transparency as a baseline requirement rather than the final measure of PBM performance.

That reflects a broader shift in how employers are evaluating pharmacy benefits vendors.

As policymakers and regulators push for greater transparency across healthcare pricing and PBM practices, benefits advisors increasingly need to understand what sits behind contractual pricing models.

A pass-through arrangement may make financial flows easier to examine, but employers still need to evaluate whether the PBM can deliver savings through formulary decisions, specialty pharmacy management, clinical interventions and channel optimization.

The result is a more sophisticated procurement process.

Rather than asking only how transparent a PBM contract is, benefits advisors may need to examine measurable outcomes such as net pharmacy costs, utilization-management performance, specialty-drug spending, implementation quality and member service.

The Enterprise MarTech Connection

Although pharmacy benefits are primarily a healthcare and HR issue, the market is also becoming increasingly dependent on technology.

PBMs and benefits platforms increasingly use data analytics, automation and clinical decision-support systems to manage pharmacy utilization and identify potential savings.

For HR and benefits teams, that creates a technology evaluation challenge similar to other enterprise software purchases. The platform itself matters, but so do data quality, integration, workflow design, reporting capabilities and the quality of human oversight.

The RxBenefits report's emphasis on clinical depth is particularly relevant to that discussion. Automation can process large volumes of claims efficiently, but employers may still require experienced clinical professionals to investigate unusual or high-value cases.

That hybrid approach—combining analytics and automation with human expertise—is becoming common across enterprise healthcare technology.

For benefits advisors, the broader message from the report is that PBM selection should be treated as an ongoing performance-management exercise rather than a one-time procurement decision.

A transparent contract may provide the foundation. The harder question is whether the vendor can consistently turn that transparency into lower net costs, appropriate utilization and a sustainable member experience.

Market Landscape

The PBM market is undergoing significant scrutiny as employers, policymakers and benefits consultants question traditional pricing structures and demand greater visibility into pharmacy economics.

At the same time, specialty medications, high-cost therapies and GLP-1 utilization are increasing pressure on employer-sponsored pharmacy budgets.

That combination is pushing employers toward more rigorous PBM evaluation. Contract transparency is increasingly important, but clinical management, formulary strategy, specialty-drug oversight and pharmacy-channel optimization can have a larger effect on actual plan costs.

The competitive market is therefore moving toward a model in which PBMs must demonstrate measurable value rather than relying primarily on contractual pricing structures.

Strategic Outlook

The RxBenefits report reflects a broader evolution in enterprise benefits procurement: employers are becoming more sophisticated buyers of healthcare technology and services.

For benefits advisors, the implication is that PBM comparisons need to extend beyond headline discounts and pass-through pricing. Vendor performance should be evaluated across clinical outcomes, implementation, member support and long-term cost management.

Technology will play a growing role, but the report's emphasis on human clinical expertise suggests that automation alone may not be enough for the most expensive and complex claims.

As pharmacy spending becomes increasingly concentrated in specialty medicines, the ability to combine data, clinical judgment and proactive utilization management could become one of the most important differentiators among PBM vendors.

Top Insights

• RxBenefits argues PBM transparency is only a baseline, with clinical management and execution determining whether employers achieve meaningful pharmacy cost savings.
• High-cost specialty medications concentrate pharmacy spending, making human clinical reviews an increasingly important component of employer benefits cost management.
• GLP-1 spending growth is intensifying pressure on self-funded employers to improve utilization management while maintaining appropriate access to treatments.
• Benefits advisors increasingly need to evaluate PBMs across savings execution, clinical depth, implementation quality, channel optimization and long-term service.
• The PBM market is moving toward measurable performance as employers demand stronger evidence that transparent contracts translate into lower net pharmacy costs.

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