Leading PBMs with transparent fee models.

The traditional pharmacy benefits manager (PBM) model is getting harder to defend. For years, the "Big three" PBMs—CVS Caremark, Express Scripts and OptumRx—have built massive revenue streams through opaque pricing structures and hidden fees. But as employers demand accountability and federal mandates require transparency, that dominance is eroding.

Leading PBMs with transparent fee models are replacing the legacy opaque pricing structures, driving adoption from just 12% in 2024 to 31% in 2025, according to the National Alliance of Healthcare Purchaser Coalitions. While traditional PBMs now offer transparency programs in response to market pressure, these are typically add-ons layered onto fundamentally opaque business models rather than core pricing structures.

In this guide, we'll explore leading PBM solutions with transparent fee models.

What are transparent fee models for pharmacy benefit managers?

Transparent fee models for pharmacy benefit managers are pricing structures where drug prices, fees and rebates are fully disclosed to the employer, so plan sponsors can see exactly how money moves through their pharmacy benefit plan.

This model is a direct contrast to traditional PBMs, which generate revenue through spread pricing (charging employers more than they pay pharmacies and keeping the difference), rebate retention (collecting manufacturer payments without passing full savings to the plan) and contract terms that obscure how money flows through the system.

It's important to understand, however, that transparency alone doesn't guarantee savings or aligned incentives. Some transparent solutions still profit from alternative fees or retain a portion of rebates—meaning visibility and value aren't always the same thing.

Which PBMs have the most transparent pricing models?

Not every PBM that claims transparency delivers it equally. While visibility into drug pricing and fees is a meaningful step forward, the most transparent pricing models go further by eliminating spread pricing, passing through 100% of rebates and removing conflicts of interest from pharmacy ownership.

Below is a look at the benefit managers with the most transparent pricing models today, evaluated on their pricing structures, factual PBM features and how well each delivers cost savings for health plans.

1. Rightway

Rightway is a pharmacy benefit manager built on a fully aligned, fiduciary model—designed to give employers complete visibility into pharmacy benefits. It operates on a single administrative fee as its only source of revenue, with no markups, retained rebates or hidden fees.

Employers see the true cost of every drug and every claim, backed by fully auditable reporting. Licensed pharmacists and pharmacy technicians proactively guide members to lower-cost options, manage specialty medications and connect them to savings programs.

Rightway also owns 0% of the pharmacy supply chain, eliminating incentives to steer members toward higher-cost options or inflate specialty drug spend. Every formulary decision is made based on clinical quality and net cost. That alignment is reinforced by the SureSpend™ model, which guarantees total drug spend and refunds 100% of any overage.

Rightway pros:

• Single admin fee—the only source of revenue, with no spread pricing or retained rebates
• 0% supply chain ownership—no pharmacy steerage or conflicts of interest
• 100% rebate and discount pass-through
• Fully auditable quarterly reporting at the claim level
• Pharmacist-led navigation guiding members to lower-cost, high-value medications

2. Navitus

Navitus operates on a 100% pass-through PMPM model, charging employers a flat per-member monthly administrative fee and passing all rebates and drug cost savings directly to the plan. Their formulary decisions prioritize biosimilars over rebate-driven brand choices, which keeps clinical and financial incentives aligned. Employers receive complete transaction visibility down to individual claims and invoices, making it straightforward to verify what they're paying and why.

Navitus pros:

• Independent PBM structure without owned retail pharmacies
• Pass-through approach to rebates and discounts
• Real-time reporting dashboards for plan oversight

Cons of Navitus:

• Pharmacist support is typically outsourced rather than embedded
• Member engagement tends to be transactional rather than personalized
• Reliance on a single pricing benchmark (NADAC) can limit flexibility
• Technology platform offers limited customization for individual member experience

3. SmithRx

SmithRx operates on a pass-through model, reporting its total spend, including all fees, clearly to employers. They offer real-time cost visibility and spending reports, and their Connect 360 offering provides drug-agnostic recommendations designed to reduce spend without favoring any particular manufacturer or pharmacy. Additional service fees are only charged when savings are achieved, which aligns their incentives with employer outcomes.

SmithRx pros:

• Pass-through PBM model with flat administrative fees
• Technology tools to help identify lower-priced medication options
• Partner portal with access to claims data and reporting

Cons of SmithRx:

• No clinical pharmacists are directly supporting members
• Member support is primarily handled through general service teams
• Limited proactive outreach and engagement with members
• Technology platform includes a web portal but no dedicated mobile app

4. AffirmedRx

AffirmedRx operates on a fixed administrative fee model with full cost breakdown transparency—separating drug costs, discounts and admin fees clearly in reporting. They emphasize relationship-driven service and customizable benefit structures, positioning themselves as an alternative to the opaque revenue models of legacy PBMs.

AffirmedRx pros:

• Transparent flat-fee pricing model with rebate pass-through
• Clinically informed formulary design focused on reducing low-value drug use
• Technology platform provides real-time reporting for plan oversight

Cons of AffirmedRx:

• Pharmacist-led navigation is not consistently embedded in the model
• Member engagement relies more on digital tools and service teams
• Clinical support may be less personalized than pharmacist-led models
• Reliance on a single index can limit pricing flexibility

5. Judi Health (Capital Rx)

Judi Health, Capital Rx's employer-facing brand, operates on a spread-free, full-pass-through model, with management fees as the only revenue source. They provide unified claims processing with real-time data access and fixed monthly payment options with underutilization refunds to give employers predictable costs.

Judi Health (CapitalRx) pros:

• Technology platform (Judi®) for real-time claims management and administration
• Transparent pricing model with flat administrative fees and rebate pass-through
• Integrated platform designed to manage multiple benefits beyond pharmacy

Cons of Judi Health (CapitalRx):

• Member engagement is primarily technology-driven rather than pharmacist-led
• Clinical support may be less personalized than models with embedded pharmacists
• Reliance on the NADAC benchmark can limit pricing flexibility
• Expansion into broader benefit administration may shift focus from PBM-specific services

Key benefits of transparent PBMs.

Employers are prioritizing transparent and fiduciary-aligned PBM structures because traditional models are built to profit from complexity. With employers predicting healthcare cost trend increases of 9% this year, according to Business Group on Health, the pressure to understand exactly where pharmacy dollars are going has never been higher. Spread pricing, retained rebates and opaque contracts make that nearly impossible in a traditional model.

Transparent and fiduciary-aligned solutions focused on outcome-based contracts change that equation, giving employers the visibility, contractual protections and incentive alignment needed to actually manage their pharmacy spend.

Predictable and stable pharmacy costs.

With a transparent PBM, employers know exactly what they're paying and why. All dispensing fees, administrative costs and prescription drug pricing are disclosed clearly, making year-over-year comparisons meaningful and budget planning straightforward. There are no surprise reconciliations, no retroactive adjustments and no revenue streams buried in the contract.

This predictability matters especially as rising drug costs continue to pressure employer budgets. Visibility makes it possible to identify cost drivers, model plan design changes and hold the benefits manager accountable to performance targets.

Key outcomes:

• Consistent, auditable cost reporting across all prescription categories
• No retroactive fee adjustments or hidden reconciliation charges
• Clear dispensing fee disclosure at the claim level
• Ability to model plan design changes with accurate cost data

Elimination of spread pricing.

PBM spread pricing is one of the most significant sources of hidden costs in traditional pharmacy benefit arrangements. The benefits manager charges the employer one price for a drug and pays the pharmacy a lower price, keeping the difference as profit. Employers often have no visibility into this spread, and it can add up to millions of dollars annually for large plans.

Most transparent solutions eliminate spread pricing entirely. This removes a fundamental conflict of interest and ensures every dollar spent on pharmacy benefits goes toward actual drug costs.

Key outcomes:

• Employers pay actual drug cost, not a marked-up rate
• Complete elimination of PBM profit from price arbitrage
• Improved trust and contract clarity between the employer and the PBM
• Easier benchmarking against market drug costs

Greater visibility into rebates.

In traditional models, manufacturers pay rebates to pharmacy benefits managers in exchange for favorable formulary placement, and PBMs frequently retain a significant portion of these rebates rather than passing the full savings to the plan sponsor. This creates an incentive to favor high-rebate drugs over lower-cost alternatives, even when the lower-cost option is clinically equivalent.

Transparent PBMs improve visibility into how rebates are structured, but visibility alone doesn't guarantee full pass-through. Many solutions operate as hybrids, passing through rebates from some channels while retaining value from others. Full rebate pass-through is the hallmark of fiduciary-aligned models, where 100% of manufacturer rebates are credited directly to the employer plan and formulary decisions are made on clinical and cost grounds alone.

Key outcomes:

• Visibility into rebate terms negotiated with drug manufacturers
• Fiduciary-aligned models return 100% of rebates to the employer plan
• Formulary decisions driven by clinical value and cost, not rebate revenue
• Reduced net drug spend, particularly for specialty and brand medications

Clearer contracts and stronger audit rights.

Traditional PBM contracts are often written to limit employer visibility, restricting audit rights, using vague definitions of net cost and including carve-outs that protect revenue streams. Employers frequently discover they cannot verify whether the benefits manager is honoring contract terms.

Transparent solutions provide contracts with clear definitions, audit rights and standardized reporting that make verification straightforward. Employers can review individual claims, confirm rebate pass-through and validate that dispensing fees match contracted rates, without needing to fight for access to their own data.

Key outcomes:

• Unrestricted audit rights with access to claim-level data
• Standardized definitions for net cost, rebates and administrative fees
• Regular reporting cadence with employer-accessible dashboards
• Contractual protections against retroactive changes or hidden fees

Better alignment of incentives and clinical decision-making.

When a pharmacy benefit manager profits from higher drug spend, clinical decisions can be influenced by financial incentives rather than member outcomes. Formulary placement, prior authorization criteria and specialty drug management all become potential revenue levers in a traditional model.

Transparent PBMs, particularly those with pharmacist-led clinical oversight, align financial and clinical incentives. Formulary decisions are made based on therapeutic value and cost-effectiveness. Prior authorization criteria are designed to ensure appropriate use, not to generate administrative revenue.

Key outcomes:

• Formulary governance based on clinical evidence and cost, not rebate value
• Prior authorization criteria are designed for appropriate use, not revenue generation
• Pharmacist oversight ensures medication appropriateness
• Incentive structure that rewards better member outcomes, not higher drug spend

How to evaluate transparent PBM pricing models.

Not every PBM that claims transparency delivers it equally. Traditional pharmacy benefits managers have long profited from spread pricing, retained rebates and opaque contracts that make it nearly impossible for employers to see where their pharmacy dollars go. Newer transparent models emerged in response—but many still include exclusion lists, cap liability and retain a share of savings.

Others pass through costs accurately but lack the clinical infrastructure to actually reduce them, leaving employers with visibility into their spend but no real mechanism to drive it down. The criteria below give employers a framework for managing pharmacy benefits with the rigor the decision deserves.

Get transparent pharmacy benefits with Rightway.

Employer pharmacy spend is climbing, and for most employers, their PBM model is to blame.

Rightway was built to change that. Our model is simple: No spread pricing, no retained rebates, no hidden incentives. Every dollar saved flows directly back to clients and members, ensuring accountability and eliminating conflicts of interest at every level.

SureSpend™ backs that up with a guarantee on total net pharmacy spend. If actual costs exceed the guarantee, Rightway refunds the difference, dollar-for-dollar, with no cap.

Here's what employers get with Rightway:

• Single admin fee—the only source of revenue, with no spread pricing or retained rebates
• 0% supply chain ownership—no conflicts of interest, no pharmacy steering
• 100% rebate and discount pass-through
• Pharmacist-led navigation guiding members to lower-cost, high-value medications
• SureSpend™ spend guarantee backed by dollar-for-dollar reimbursement with no cap

Book a demo today and see why Rightway is the best choice for enterprises exploring leading PBMs with transparent fee models.