SHARx calls for closer scrutiny of PBM contracts

ST. LOUIS — Employers considering a change in pharmacy benefit managers should look beyond rebates, discounts and other contractual guarantees to determine whether a new arrangement will actually reduce prescription drug costs and improve access, according to SHARx.

The prescription drug procurement company said increased competition among PBMs does not necessarily mean employers are choosing among fundamentally different business models.

Citing a 2025 National Alliance of Healthcare Purchaser Coalitions survey, SHARx noted that 61% of purchasers had changed PBMs during the previous year or were considering a change within one to three years. Use of PBMs identified by purchasers as transparent increased from 12% to 31%, while reliance on the three largest PBMs declined from 72% to 61%.

“Changing the vendor does not solve the problem if every vendor is evaluated under the same old rules,” said Paul Pruitt, chief growth officer of SHARx. “If the model is part of the problem, employers have to reconsider what they expect from the ground up.”

Traditional PBM requests for proposals typically compare factors including discounts from average wholesale price, rebate guarantees, administrative fees and pharmacy network access. SHARx argues that employers should also examine the net amount ultimately paid for medications and the financial incentives underlying each arrangement.

“What matters is what the employer actually pays for the medications its people use,” Pruitt said. “A proposal can deliver the promised discount and still result in plan overpayment.”

Pharmacy costs have become an increasingly significant part of employer health spending. Business Group on Health has reported that pharmacy’s share of employer health care spending increased from 21% in 2021 to 27% in 2023. The organization has also encouraged employers to consider vendor performance, measurable outcomes, contract transparency and alignment with broader workforce objectives when reviewing pharmacy benefit arrangements.

SHARx said employers and benefits brokers should examine how prospective vendors generate revenue, including the roles played by affiliated specialty pharmacies, rebate aggregators, group purchasing organizations and subcontractors. Employers should also consider who determines where members can fill specialty prescriptions and whether financial incentives increase alongside prescription volume or drug spending.

The company also recommends evaluating what employers will be able to verify after a contract takes effect, rather than relying solely on transparency commitments made during the bidding process.

“Anyone can make a claim in a proposal,” Pruitt said. “The test is whether the employer can see the arrangement working in practice without waiting a year for an audit.”

Beyond financial terms, SHARx said PBM requests for proposals should address implementation, member support, service commitments and measurable cost and access outcomes.

“The strongest brokers are not negotiating the old model harder,” Pruitt said. “They are helping employers determine what should work differently, which outcomes matter, and whether the options in front of them can actually produce those results. Otherwise, the RFP may change the vendor without changing the problem.”