Transparency, Tested

When “Transparent” PBMs Fail the Fiduciary Audit

Executive Brief

The 2025 PSG Pharmacy Benefit Manager Customer Satisfaction Report shows employers are demanding more transparency from PBMs.

Two findings stand out:

• Transparency: The Big Three PBMs (CVS, Express Scripts, Optum) were rated 25% less transparent than all others.
• Procurement: Over half of employers are very or extremely interested in including non–Big Three PBMs in their next procurement.

But here’s the real question:

How do you know how transparent your PBM really is?

Perception often lags reality. Without routine contract monitoring—or better yet, an audit—“transparency” becomes a marketing word, not a measurable fact.

That’s why we developed the Nautilus PBM Contract X-Ray: an easy way for employers to quantify transparency and fiduciary alignment, clause by clause.

Case Study: Contract X-Ray in Action

We recently compared a real PBM contract—from a company that publicly claims transparency—against the Nautilus Model Contract Language every fiduciary should require.

Here’s what we found:

• Over half the fiduciary protections were missing or weakened
• Audit rights were conditional, not absolute
• Rebate definitions were ambiguous, enabling hidden margins
• Data ownership favored the PBM, not the plan sponsor
• Fiduciary disclosures required by the CAA/ERISA were absent

The PBM’s website said: Transparent. Pass-Through. Fiduciary Aligned.

The contract told another story.

Contract Compliance Comparison

Below are findings from our Contract X-Ray, identifying transparency and fiduciary compliance gaps in the PBM’s agreement. Each row shows the model provision, fiduciary standard, and how the current contract deviated.

This isn’t just an audit table.

It’s a blueprint for accountability—a way to document, verify, and remediate PBM contracts to meet fiduciary duties and protect plan participants.

The Fiduciary Lesson

Fiduciary alignment isn’t about who says they’re transparent.
It’s about who can prove it—in writing.

Every employer now has the tools to separate marketing from reality:

• Use the Nautilus Contract Compliance RFI
• Benchmark your PBM’s clauses against fiduciary standards
• Demand written confirmation not verbal reassurance

Your mantra need to be:

“Don’t just say it. Prove it”

Key Takeaways

• The PSG report confirms momentum toward fiduciary alignment
• Even “transparent” PBMs may hide behind weak clauses
• True transparency is measurable, verifiable, and enforceable
• The Nautilus Contract Compliance RFI exposes the gap—and provides the fix

Two Ways to Take Action

Option 1: Do It Yourself

Visit the Nautilus PBM Project site to download:

• The full Contract Compliance RFI
• Model contract language for each of the 28 fiduciary clauses
• PBM Configurator tools to gauge your PBM's adherence to required language

Your toolkit to verify transparency and strengthen compliance.

Option 2: We’ll Do It for You

Prefer expert eyes on the fine print? Send us your PBM agreement, and the Nautilus team will:

1. Conduct a Contract X-Ray against the 28 fiduciary standards
2. Create a Risk Analysis identifying missing or non-compliant clauses
3. Draft a Contract Compliance RFI ready to send to your PBM

You’ll get a clear picture of where your PBM stands and a plan to close gaps.

Because fiduciaries don’t just trust. They verify.

🎯 No sales pitch. No pressure. Just results.

Hit reply with one sentence:
​“I’m ready to issue the RFI.”

We’ll handle the rest.

A Note of Thanks

​Mark Mincy, Chief Commercial Officer at US-Rx Care, has over 40 years of pharmacy leadership experience. Mark is on a mission to educate employers on avoiding conflicts of interest in pharmacy procurement and management. He was a valuable contributor and editor to the PBM Field Guide and a consistent advocate for transparency that’s not just promised, but proven.

Deep gratitude to everyone who built this toolkit: Nautilus and Health Rosetta leadership, expert advisers, and PBMs committed to transparency. Explore the model PBM contract language and apply for early access to the Nautilus PBM Configurator at: 🔗 ​nautilushealth.org/pbm​

New Tools & Resources Live Now

Here’s what you’ll find at nautilushealth.org/pbm (go ahead, bookmark it):

Visit nautilushealth.org/pbm to find educational resources, procurement tools, model contract terms, the PBM Configurator, and other tools.

💸 SPECIAL OFFER: Newsletter subscribers receive 10% off any Validation Institute service. Use code FIDUCIARY10 at checkout.

📬 PAY IT FORWARD: Feel free to forward this offer to your broker, PBM, or other vendors. Don't hesitate to tell them you will favor validated vendors as part of your modernized procurement processes. Strong compliance and better benefits begin with validation.

Don't be a bystander. Change the status quo and reap the benefits of The Health Plan Compliance Advantage.
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