Are Market Checks Worth It for Your Pharmacy Benefit?

August 2025
At Crystal Clear Rx, we talk with plan sponsors every day who feel uncertain about what they’re actually paying for when it comes to their pharmacy benefit. Costs are rising, utilization is shifting, and pharmacy benefit managers (PBMs) are offering fewer answers and more bundled promises.

That’s why many of our clients ask us the same question: Is it worth doing a market check on our PBM contract?

Here’s our honest take, if it’s done right, a market check is one of the most efficient ways to protect your plan and ensure you’re not leaving money on the table.

What We Mean by a Market Check

A market check is a deep, structured review of your current PBM contract. It compares your pricing, rebates, and contract terms against current market benchmarks. It’s not just about the numbers, it’s about context. Are your discounts still competitive? Are your rebate terms aligned with what’s possible today, not what was available two years ago? Are you locked into definitions and clauses that no longer serve your members?

A market check doesn’t have to be disruptive. You don’t need to be in the middle of an RFP or preparing to switch vendors. In fact, most of the market checks we conduct are mid-contract, and the result is simply stronger terms from the same PBM you’re already using. When you have current data and an independent review behind you, you gain leverage often without needing to make a dramatic change.

The Pharmacy Benefit Market Moves Quickly

In pharmacy, a lot can change in a short period of time. Drug launches, rebate shifts, generic competition, state and federal regulations, manufacturer strategies, and all of it evolves rapidly. What was a good deal 18 months ago might already be below market today. And if you haven’t reviewed your pricing against current standards in the last year or two, there’s a good chance you’re overpaying.

That’s one of the main reasons we encourage market checks, not to point fingers or call out PBMs, but to help you stay aligned with the market. PBMs know the trends. They track the shifts. If you’re not doing the same, you’re negotiating from a weaker position.

Why Transparency Still Matters

One of the biggest challenges for plan sponsors is that PBM pricing structures are hard to read. Spread pricing, rebate retention, performance guarantees, specialty carve-outs. It’s a complicated landscape. And without a benchmark, it’s nearly impossible to know whether your contract is working for you or just looking good on paper.

At Crystal Clear Rx, we often uncover hidden value in the fine print. Maybe your rebates are solid, but your audit rights are limited. Maybe you’re locked into a pricing model that benefits the PBM’s mail-order pharmacy more than your plan. Maybe you’re seeing higher-than-expected utilization, but no one has dug into the clinical controls to explain why.

A market check helps you cut through that fog. It’s not about finding a perfect deal, it’s about finding out whether your current one is still fair.

What Plan Sponsors Gain

The return on a market check can be significant. We’ve seen plan sponsors recover dollars they didn’t realize they were overspending—just by renegotiating the terms they already had. Sometimes the impact is financial: improved rebates, lower admin fees, tighter MAC pricing. Sometimes it’s structural: better audit rights, stronger definitions, more control over utilization management.

And beyond savings, it’s also about strategy. A good market check doesn’t just tell you what to fix. It helps you think about how your pharmacy benefit supports your broader goals. Are you prioritizing member access? Are you managing specialty trend? Are you ready to carve out what’s not working?

What We’ve Learned from Experience

Here’s what we know: The best time to do a market check is before your renewal—or better yet, mid-contract when you still have time to renegotiate. Many contracts include clauses that allow for performance or pricing reviews, even if you’re not actively going out to bid. If you’ve never used that clause, now might be the time.

And if your PBM tells you you’re getting their best deal, ask them to show their work. If they can’t or won’t, that’s a red flag. You have a fiduciary responsibility to your members and your organization. A market check helps you fulfill it.

The Bottom Line

If it’s been more than 18–24 months since you last reviewed your PBM pricing, a market check isn’t just worth it, it’s overdue.

Want to explore whether a market check makes sense for your plan?

Reach out. We’ll walk you through it. Contact Us Crystal Clear Rx or https://www.linkedin.com/company/crystal-clear-rx/