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Most employers are shown specialty drug pricing through discounts off list, rebate guarantees, and year-end projections.
On paper, this can feel reassuring.
In reality, those figures rarely reflect what the plan actually pays.
At the claim level, specialty medications move through multiple pricing layers. These include acquisition cost, some PBM pricing practices, administrative fees, and rebates that arrive months after the claim is paid. Each layer reduces visibility into true cost and makes it harder for employers to understand where their pharmacy dollars are really going.
Rebates are one of the biggest sources of confusion. They are paid after claims are incurred and are not tied to individual member outcomes. In many cases, higher rebates are driven by higher list prices. The plan pays more at the point of sale in order to receive a larger check later. That is not savings. It is delayed reconciliation.
Employers that gain control over specialty spend focus on true unit pricing. They understand what the plan pays per prescription at the time the medication is dispensed. This approach improves cash flow, strengthens forecasting, and reduces stop-loss volatility. Pharmacy spend becomes something that can be actively managed rather than explained after the fact.
A PBM analysis that looks past guarantees and rebate projections and down to claim level economics is no longer optional. It is the only way to determine whether a specialty strategy is actually working for the plan.
If you want to know what your plan is really paying and where real savings exist, the starting point is a PBM cost and pricing analysis with Aphora Health . We will be happy to show you how we can save you money right now.
Visit us at https://aphorahealth.com/contact-us to find out how much you can save!
