Nobody knows which employee has a $300,000 year coming. But the plan around that year — the contracts, the pricing, the steering, the structure — is a set of levers. Most of them have never been touched.
Who gets sick, when a baby comes early, which diagnosis lands. This is genuinely unpredictable — and any broker who prices next year off a promise about it is selling weather forecasts.
What a drug actually costs after rebates. Where care happens. How a big claim is financed and how it's counted at renewal. Whether you can even see your own data. These are contracts and decisions — not luck.
You don't control the weather. You control the roof.
Drug makers pay large rebates to PBMs for putting their drugs on the formulary. The question that decides your pharmacy spend isn't the rebate — it's who keeps it. Flip the contract type and watch the same $100 land differently.
Under a traditional contract, the PBM keeps a share of the rebate, prices the drug above its own cost ("spread"), and collects per-claim fees. The plan sees a discount — and misses most of the value.
Numbers are illustrative — actual rebate splits, spread, and fees vary by contract. That variation is exactly the point: it's negotiated, which means it's a lever.
Go deeper: where your Rx dollars actually go →A sample employer — 100 employees, about $1.2M in annual medical and pharmacy spend. Pull the levers and watch the managed range build. One rule first: the board doesn't power on without data.
Board locked. You can't pull levers you can't see. Claims data access is the master switch — flip it first.
Ranges reflect published industry studies and typical engagement results — illustrative only, not a quote or a guarantee. Your levers get sized from your data, not a sample.