What should a PBM RFP ask for to capture leak opportunities?

A PBM RFP designed to capture the leak opportunities the federal data exposes should include several specific contract provisions that legacy contracts typically lack:

1. NADAC pass-through pricing on the top 10-25 leak molecules. Bring the molecule list from your leak report to the RFP. Ask every PBM to commit to NADAC + dispensing fee on these specific NDCs. Refusal or hedge is itself a signal.

2. Right to mid-year tier moves on generic-rich molecules. For any drug with 10+ FDA-approved ANDAs, ask for contractual authority to move tiers mid-year without amendment. Most legacy contracts block this.

3. Quarterly transparency reports per molecule. Net cost, rebate flow, spread per drug per quarter. PBMs comfortable with their pricing structure agree. Those uncomfortable invent process objections.

4. Specialty pharmacy markup disclosure. Per-NDC markup over NADAC on all specialty drugs dispensed through the PBM-owned specialty pharmacy, reported quarterly.

5. No rebate guarantees on molecules with 10+ generic manufacturers. Decouples PBM revenue from preserving brand utilization on drugs where competitive pricing exists.

6. Audit right. Independent third-party access to claims-level pricing data for a sample of molecules annually.

7. Termination for cause on transparency failures. If quarterly reports are missing or inaccurate, plan can terminate without standard early-exit fees.

These provisions reflect what the FTC's 2024 report identified as the structural protections plans need to capture savings opportunities. Whether you get them depends on plan size, RFP timing, and competitive pressure on the PBM at the time of negotiation.