Research directory
Topics
Follow a contract question into the evidence. Every topic is a real Commons rubric criterion.
Accountability & disclosure
4 criteria
- FIDFiduciary duty and loyaltyWithout a loyalty duty the PBM is free to put its own affiliates and revenue ahead of the plan when it exercises discretion over formularies, networks and pricing.Weight 7/100
- DISCFull disclosure of compensation and conflictsHidden revenue streams are the main way plans overpay. Officer certification puts a name on the line.Weight 6/100
- OWNOwnership and affiliate disclosure exhibitThe model contract has no ownership exhibit, and the Nautilus Health Institute review of version 3.5 scored conflict of interest 70 of 100 for that gap. A plan cannot police affiliate pricing, steering or GPO pass through if it does not know which companies are affiliates.Weight 3/100
- DEFDefinitions that close loopholesMost PBM revenue leakage happens inside definitions. A narrow definition of rebate lets fees, grants and administrative payments stay with the PBM.Weight 5/100
Revenue & pricing
7 criteria
- PASS100% pass-through of manufacturer revenueRebates and other manufacturer payments are the largest dollar item in most PBM contracts. Anything less than 100% of everything is money left with the PBM.Weight 11/100
- NACAffiliate pharmacy pricing at acquisition costOwned pharmacies are where PBMs earn the most margin. Pricing them at cost removes the incentive to steer patients into the PBM's own channels.Weight 5/100
- CEILBenchmark ceiling and cheapest lawful optionA ceiling protects the plan from paying more through the contract than the public can pay in cash, and a claim level test stops a favorable average from hiding individual overcharges.Weight 3/100
- SPRDNo spread pricingSpread pricing is an undisclosed markup on every claim. Eliminating it is the single clearest test of a transparent contract.Weight 9/100
- GPOGPO and purchasing entity pass-throughPBMs moved much of their manufacturer revenue into affiliated GPOs after rebate scrutiny increased. A contract that only covers rebates misses this.Weight 4/100
- MFNMost favored pricing and market checkMulti-year contracts drift out of market. Without a market check the plan is locked into stale pricing.Weight 3/100
- SPECSpecialty drug pricing controlsSpecialty drugs are a minority of claims but the majority of spend, and most are dispensed by PBM-owned specialty pharmacies.Weight 3/100
Patient access & pharmacy choice
5 criteria
- CASHCash price protection and deductible creditMembers routinely pay more through the plan than the cash price on the shelf, and a cash purchase that does not count toward the deductible punishes the member for finding the cheaper price.Weight 3/100
- MACMAC list governanceTwo MAC lists (one for the plan, one for pharmacies) is the classic spread pricing mechanism.Weight 5/100
- FORMPlan sponsor controls the formularyA PBM-controlled formulary can favor high-list-price, high-rebate drugs that cost the plan more overall.Weight 4/100
- LNCLowest net cost standard and book of business comparisonRebate driven formularies can favor a high list price drug that returns more rebate but costs the plan more after the rebate. A stated standard and a book of business comparison make that trade visible.Weight 3/100
- NETPharmacy network protections and anti-steeringSteering and clawbacks push independent pharmacies out and route patients to PBM-owned channels, reducing choice and often raising cost.Weight 7/100
Data, audit & transparency
3 criteria
- AUDAudit rights, data access and reportingYou cannot enforce what you cannot see. Audit and data rights are how every other clause gets verified.Weight 6/100
- DATAPlan sponsor owns all plan dataData ownership decides who can switch vendors, run an audit or check a guarantee. A PBM that owns or licenses plan data can charge for it, withhold it at termination, or resell it.Weight 4/100
- GAGGag clause (red flag)Confidentiality clauses that treat pricing terms as trade secrets are what keep taxpayers from seeing what their government pays. This is why the A&M contract is partly blacked out.Red-flag check
Enforcement & exit
4 criteria
- PERFPerformance guarantees with real remediesGuarantees that are capped or measured on book-of-business data rarely pay out.Weight 2/100
- ENFSelf executing enforcement and two strikes exitA right the plan has to litigate to enforce is rarely enforced. Automatic remedies and a defined exit after a repeat failure change the PBM incentives without a lawsuit.Weight 3/100
- AMDAmendments only in writingUnilateral amendment rights let a PBM quietly rewrite pricing mid-term.Weight 2/100
- TERMTermination without penaltyTermination penalties and forfeited rebates are how plans get trapped in bad contracts.Weight 2/100
Research topics, not empty channels
Each topic opens the published evidence for a real record. Rubric criteria are not discussion counts, followers or evidence of agency participation.