PBM Renewals Demand Evidence of Financial and Clinical Performance

Rising prescription drug costs are prompting employers to examine what their pharmacy benefit managers (PBMs) charge and how they manage medication coverage. Before renewing a contract, employers should verify total plan spending after rebates, confirm that promised drug discounts and rebate payments were delivered and examine whether clinical programs reduce unnecessary spending and help members receive effective treatment.

These findings help employers decide whether to keep their current PBM or select another provider. A recent pharmacy benefits survey found that 87% of surveyed employers said they were likely to switch PBMs at renewal. The research included 601 employers and 300 employee benefits consultants and advisors with pharmacy benefit decision-making authority.

The report identifies clinical management as a primary basis for provider evaluation, with GLP-1 strategy assessed separately through coverage controls, step therapy and program design. It also finds that transparency has become a basic expectation. Describing a model as transparent does not establish its financial or clinical results.

At RxLogic, we recognize that changing the PBM relationship may bring different contract terms or clinical services, but those proposals still need to be implemented and evaluated. For PBMs seeking to retain or win employer accounts, this makes consistent administration and evidence of delivery part of the case for their business. Employers need a way to determine whether the new arrangement improves on the one it replaces.

Our team is here to support employers that are contemplating a switch. RxLogic delivers a cloud-native, conflict-free SaaS technology platform that executes pharmacy claims adjudication operational workflows within the claim lifecycle, giving PBMs configurable technology to administer their programs and support employer oversight.

RxLogic Connects Program Design with Execution and Review

PBMs can configure benefit and pricing requirements within RxLogic’s operational workflows. As claims are adjudicated, the platform executes network pricing rules, validates pricing and handles configured exceptions. Prior authorization (PA) data and workflows connect directly to that processing, enabling real-time status checks and coordination with clinical partners.

The adjudicated claim supplies transaction data for rebate eligibility processing and contract term execution. Rebate workflow automation supports financial reconciliation, while PayRec automates payment files and invoices with supporting claim-level detail. The financial records remain attributable to the claims that produced them.

That claim-level detail supports financial reviews and performance guarantee monitoring. PBMs can compare reported amounts with underlying transactions and investigate discrepancies, providing employers with evidence of how their benefit dollars were administered. Evaluating treatment effectiveness separately requires patient outcome data from the clinical program.

Clients Retain Control of Their Programs

RxLogic is not a PBM and supports clients without competing for their business. Clients retain control over program design, data and vendor relationships. Its modular capabilities and shared API framework allow PBMs to connect selected services and clinical partners, supporting changes in an employer’s requirements without dictating which partners the PBM must use.

Contact RxLogic today to learn how our system would administer your program requirements and what records your team could use to substantiate performance during renewal discussions with employer clients.