"Pass-Through" Isn't a Strategy
(And Sometimes Isn't Real)
"Pass-through" is one of those phrases that sounds like transparency and feels like safety. But unless the contract defines every category clearly and reporting is claim-level reconcilable, pass-through can still be a magic trick.
Where Margin Still Hides
Even with a "pass-through" contract, PBMs have sophisticated ways to retain margin that aren't immediately visible. Understanding these mechanisms is the first step to real transparency.
Common Hidden Margin Locations
- Specialty classification: What counts as "specialty" can move, and specialty has different economics
- Pharmacy reimbursements: Spread can exist by channel (retail vs mail vs specialty)
- MAC list construction: How it's built, update frequency, and appeals process matter
- Network differentials: Preferred vs non-preferred pharmacy economics
- Hidden fees: Manufacturer payments labeled as data, admin, or clinical fees, not "rebates"
The Adult Test
The test is simple: can the PBM tie invoices to claim lines and show the economics at the drug level? If not, you're buying a vibe. And vibes are expensive.
What to Do Next
Use a structured checklist (like the Leak Map) and insist on clear definitions and audit-ready reporting. You don't need to be hostile—you just need to be specific. Transparency isn't a promise. It's documentation.
Want the Leak Map?
Download our checklist to identify where your plan might be leaking money, or book a demo to see the War Room.
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