The PBM RFP: What to Ask and What the Answers Actually Mean

30 questions organized by category with answer scoring rubrics that reveal what PBM responses actually mean

A PBM RFP should ask 30 specificity-forcing questions across six categories (pricing and guarantees, rebate structure, clinical programs, reporting and transparency, contract terms, and implementation), each scored 0 to 3 on a 90-point rubric, because a standard RFP lets every PBM answer vague questions with impressive-sounding but uncommitting language, so the response that looks cheapest can be the most expensive once the pricing methodologies are normalized.

A client’s broker brought us in to evaluate three PBM RFP responses. On paper, all three looked competitive. The pricing spreads were narrow. The guarantees were similar. The clinical programs sounded comparable.

When we normalized the pricing methodologies and asked specific follow-up questions, one was substantially more expensive than the others despite appearing cheapest in the initial response. The discount methodology used a different AWP base. The rebate guarantee excluded specialty claims. The “performance guarantee” had a penalty cap so low it was effectively meaningless.

The RFP was designed to be won, not to be understood. And that is the structural problem with how most PBM evaluations work.

Below is the question bank we use to fix it: thirty questions across six categories, each with what a good answer looks like, what a red flag looks like, and the follow-up that closes the gap when an answer goes vague. At the end you get the 0-3 scoring rubric that turns thirty answers into one 90-point number you can rank on.

Why standard RFPs fail

Most PBM RFP templates were written by consultants, PBMs, or industry associations. They ask questions PBMs are prepared to answer in ways that make their responses look competitive. The questions are not wrong. They are insufficient.

Standard RFPs ask: “What is your generic discount off AWP?” A PBM can answer this with a number that looks competitive but uses a different AWP reference price than their competitor, making direct comparison impossible. Standard RFPs ask: “Do you offer clinical management programs?” Every PBM says yes. The question does not reveal whether those programs produce verifiable savings or generate administrative friction that outweighs their value.

The problem is not that employers ask bad questions. It is that the questions do not force specificity, and PBM response teams know exactly how to answer vague questions with impressive-sounding but uncommitting language.

The RFP question bank

I built this question bank at Prescription Benefit Solutions over years of evaluating PBM proposals with clients. Thirty questions organized in six categories. Each question includes four elements: why it matters, what a good answer looks like, what a red flag answer looks like, and a follow-up question to ask if the initial answer is vague.

The scoring rubric (0-3 per question) produces a 90-point evaluation that normalizes responses across PBMs.

Category 1: Pricing and Guarantees (6 questions)

Question 1: What AWP source and update frequency does your pricing guarantee reference?

Why: Different AWP sources produce different base prices. A “competitive” discount off one AWP source may be less competitive than a smaller discount off another. Good answer: Specifies the exact AWP source (Medi-Span, First DataBank), update frequency, and effective date methodology. Red flag: “Industry standard AWP” without specifying the source. Follow-up: “Will you contractually commit to a specific AWP source for the contract term?”

Question 2: Are pricing guarantees calculated at the ingredient cost level or the total claim level?

Why: Ingredient cost excludes dispensing fees and taxes. Total claim cost includes everything the plan pays. Guarantees at ingredient level can look stronger while total cost is higher. Good answer: Specifies the calculation methodology with examples. Red flag: Does not distinguish between ingredient and total claim cost.

Question 3: Do pricing guarantees apply to all claims or are any claim types excluded?

Why: Excluding specialty, compound, or limited distribution claims from guarantee calculations can significantly affect the actual pricing the plan receives. Good answer: All claims included, or specific exclusions listed with rationale. Red flag: Vague language about “standard claims” or “eligible claims” without defining either.

Question 4: Who sets and updates the MAC list, how often, and will the plan receive it?

Why: The MAC list is the PBM’s own price ceiling on generics. If the PBM writes it, updates it on its own schedule, and never shows it to the plan, the generic guarantee is measured against a number only one party can see. Good answer: Named update cadence, the plan receives the list on request, and a defined process for challenging a price. Red flag: “Proprietary methodology,” or the list is available only in summary form. Follow-up: “Will you contractually commit to providing the MAC list on request during the term?”

Question 5: How often are pricing guarantees reconciled, who audits the true-up, and when is the plan actually paid?

Why: An annual reconciliation done months late, on the PBM’s own math, is a guarantee the PBM finances with the plan’s money. The rate matters less than the timing and the arithmetic behind it. Good answer: Quarterly reconciliation, methodology provided, independent audit permitted, payment inside a stated number of days. Red flag: Annual reconciliation, no audit right, no payment deadline. Follow-up: “If reconciliation shows a shortfall, is it paid in cash, and by what date?”

Question 6: Itemize every fee the plan will pay, and cite the contract section that authorizes each one.

Why: Administrative, clinical, network access, data, and per-claim fees are often bundled in a proposal and unbundled on the invoice. Line items with no clause behind them are the ones that get cut. Good answer: A complete fee schedule, each item tied to a contract section, with a statement that no other fees will be charged. Red flag: A single blended per-claim admin figure with “other pass-through costs as incurred.” Follow-up: “Will you warrant in the contract that this schedule is the complete list of fees?”

Category 2: Rebate Structure (5 questions)

Question 7: Provide your complete definition of “rebate” as it will appear in the contract.

Why: The definition determines what gets passed through. Everything downstream, including the guarantee, is measured against whatever this paragraph says a rebate is. Good answer: Inclusive definition covering all manufacturer payments related to plan utilization. Red flag: “Manufacturer rebates as customarily defined in the industry.” Follow-up: “Does this definition include admin fees, price protection, and formulary access payments?”

Question 8: Are specialty claims included in the rebate-eligible denominator?

Why: Specialty generates the highest per-claim rebates. Excluding them can mean significant retained revenue. Good answer: “Yes, all specialty claims processed through any channel are rebate-eligible.” Red flag: Specialty excluded or handled under a separate “specialty rebate” arrangement with different terms.

Question 9: Does any affiliated entity, group purchasing organization, or rebate aggregator retain a fee before the pass-through percentage is calculated?

Why: This is the question that separates a real pass-through from a nominal one. A PBM can pass through 100 percent of what it received while an affiliated entity it owns or contracts with takes a fee off the manufacturer payment first. Good answer: Names every affiliated entity in the chain, discloses each fee, and commits that the guarantee is measured on the manufacturer’s gross payment. Red flag: “We pass through 100 percent of rebates received.” The operative word is received. Follow-up: “Will you define the rebate guarantee against total manufacturer payments, inclusive of affiliate and aggregator compensation?”

Question 10: When are rebates paid to the plan, and what happens to rebates earned on our claims if the contract terminates mid-year?

Why: Rebates arrive on a lag. A forfeiture clause can leave months of rebates earned on the plan’s own claims behind when the plan leaves, which quietly raises the cost of exiting. Good answer: A stated payment lag, and rebates earned during the term are paid regardless of termination. Red flag: Rebates “forfeited” on termination, or payment contingent on the plan being an active client when the rebate is received.

Question 11: If a rebate guarantee is missed, what is the remedy, and is there a cap?

Why: A guarantee with a low penalty cap, or one payable as a credit toward future services, lets the PBM settle a miss in its own currency. Good answer: Cash payment of the full shortfall, no cap, paid inside a stated period. Red flag: A credit toward future services, a cap well below realistic exposure, or a remedy tied to renewal.

Category 3: Clinical Programs (5 questions)

Question 12: For each clinical program, provide the savings methodology and a sample calculation.

Why: PBMs report “clinical savings” using methodologies that may count avoided costs or attribute formulary-driven savings to clinical programs. Good answer: Specific methodology with sample calculation, independently auditable. Red flag: “Proprietary methodology” or aggregate savings without per-program detail.

Question 13: Which formulary exclusions on a plan like ours are driven by rebate economics rather than clinical evidence, and how are P&T conflicts disclosed?

Why: Formulary placement is where clinical language and rebate economics overlap. The plan is entitled to know which of the two is driving a given exclusion. Good answer: A stated process separating clinical review from rebate negotiation, with conflict disclosure and a plan-level exception path. Red flag: “All formulary decisions are clinically driven,” offered with no documentation. Follow-up: “Will you notify us in advance of exclusions that change a member’s current therapy, and give us an opt-out?”

Question 14: Provide prior authorization approval, denial, and appeal-overturn rates, average turnaround time, and confirm whether the plan may review the criteria.

Why: A high appeal-overturn rate means the criteria are generating friction rather than clinical value, and the plan absorbs the administrative cost either way. Good answer: Actual rates for comparable books of business, turnaround in hours or days, criteria available to the plan. Red flag: Criteria withheld as proprietary, or rates offered only as an industry average.

Question 15: Describe the step therapy override process, who decides, and how often overrides are granted.

Why: Step therapy only works if the exception path functions. A process that technically exists but rarely grants an override transfers cost into member abrasion and HR escalations. Good answer: A named clinical decision-maker, a stated turnaround, and override rates the PBM will share. Red flag: “Case by case” with no timeline and no data.

Question 16: For each clinical program, state the fee basis: flat, per-member, per-claim, or a percentage of savings.

Why: When a vendor is paid a percentage of savings, the vendor controls the definition of savings. That is a structural conflict, not a pricing preference, and it belongs on the table before selection. Good answer: Flat or per-member fees, or a percentage arrangement where the savings definition and the audit right are both in the contract. Red flag: Percentage of savings with the methodology described as proprietary. Follow-up: “Who calculates the savings the fee is based on, and may we audit that calculation?”

Category 4: Reporting and Transparency (5 questions)

Question 17: Will the plan have access to raw claims data in a standard file format?

Why: Summary reports are curated by the PBM. Raw data enables independent analysis. Good answer: “Yes, monthly claims file in NCPDP standard format, available within 30 days.” Red flag: “Reports available through our portal” without raw data access.

Question 18: How are you compensated on our plan, by category, in dollars, including any compensation from manufacturers and other third parties?

Why: The Consolidated Appropriations Act gives plan sponsors the right to a real answer to this question. Most plans have never used it, and an RFP is the cleanest moment to. Good answer: A written breakdown by revenue category, with a commitment to update it annually during the term. Red flag: A response that describes only the administrative fee, as though it were the whole of the compensation.

Question 19: Provide your standard audit provision. Who selects the auditor, who selects the records, who determines whether findings count, and when does the audit window close?

Why: Nearly every PBM contract grants an audit right. The four answers above decide whether it is an audit or a guided tour. Good answer: The plan selects an independent auditor, full claims-level records, findings binding with a defined remediation period, and a window that does not expire in months. Red flag: PBM-approved auditors, sampling chosen by the PBM, findings subject to PBM concurrence, or a short window after the claim date. Follow-up: “Will you accept an auditor of our choosing under a standard confidentiality agreement?”

Question 20: List the standard reporting package and cadence, and identify which metrics you are financially accountable for versus which you merely report.

Why: The metrics a PBM is paid on explain program design better than any presentation does. Everything else is narrative. Good answer: A report inventory with cadence, and a clear split between guaranteed metrics and informational ones. Red flag: A long metric list with no indication which carry dollars behind them.

Question 21: Who owns the claims data, and what does it cost the plan to retrieve it at termination?

Why: Data ownership decides how hard it is to run the next market check, and how long a transition takes. It is a pricing term disguised as an IT term. Good answer: The plan owns its data, receives it in a standard format at no charge, within a stated number of days of termination. Red flag: Extract fees, “reasonable cost” language, or no stated turnaround.

Category 5: Contract Terms (5 questions)

Question 22: Provide your standard termination provision, including notice period and termination for cause triggers.

Why: Termination provisions determine your exit options and renewal leverage. Good answer: 90-day termination for convenience, specific cause triggers listed. Red flag: 180-day notice with limited cause triggers.

Question 23: Does the contract auto-renew, and what is the exact date by which the plan must act to prevent it?

Why: Evergreen renewal language turns inaction into a multi-year commitment. The notice clock usually runs well before the renewal conversation the plan expects to be having. Good answer: No auto-renewal, or auto-renewal with a clearly stated notice date the PBM will confirm in writing each year. Red flag: Automatic renewal for a full term, with notice required six months or more in advance. Follow-up: “Will you send written notice to the plan 30 days before the notice deadline each year?”

Question 24: Can pricing, the MAC list, the formulary, or any fee change during the term without the plan’s written consent?

Why: A guarantee that can be amended unilaterally is not a guarantee. This is where a well-negotiated rate quietly becomes a different rate. Good answer: No material change without written consent, with a defined process and the plan’s right to terminate if it declines. Red flag: Change permitted on notice, or “in response to market conditions.”

Question 25: Provide the complete definitions exhibit as it will appear in the contract, including generic, brand, specialty, single-source, mail, rebate, and pass-through.

Why: Reclassifying a drug from one defined category to another moves real money without changing a single published rate. The definitions exhibit is where that becomes possible or impossible. Good answer: A full exhibit, with a stated process and plan consent for any reclassification during the term. Red flag: “Industry standard definitions,” or definitions the PBM may update at its discretion. Follow-up: “Which drugs on our current claims would be classified differently under your definitions than under our existing contract?”

Question 26: List every performance guarantee, its remedy, and its cap, and state whether remedies are paid in cash.

Why: A service level with a credit-toward-future-services remedy lets the PBM pay its penalties in its own currency. The cap tells you how seriously the guarantee was meant. Good answer: Cash remedies, caps that are meaningful against the guaranteed metric, and an annual true-up. Red flag: Service credits, aggregate caps across all guarantees, or remedies that require the plan to renew to collect.

Category 6: Implementation (4 questions)

Question 27: Provide a detailed implementation timeline with milestone dates, responsible parties, and risk mitigation plan.

Why: Implementation failures affect member experience and plan cost. Good answer: Week-by-week timeline with named project manager, escalation procedures, and financial penalties for missed milestones. Red flag: “Standard 90-day implementation” without specifics.

Question 28: Run our claims against your network and formulary and state what share of members change pharmacy or therapy, and what that estimate depends on.

Why: Every finalist produces a disruption report. The report is real; the assumptions are the product. The number that matters is what happens to it when the formulary changes in year two. Good answer: A member-level disruption estimate, the assumptions stated, and a commitment to notify the plan before mid-term formulary changes that would increase it. Red flag: A low disruption percentage with no assumptions disclosed. Follow-up: “What does this number become if your formulary excludes two of our top ten drugs next year?”

Question 29: Are you offering an implementation credit or signing allowance, and exactly how is it recovered over the term?

Why: A credit is money now, earned back through the pricing later. The credit is always visible in the proposal. The earn-back rarely is, and a deal that leads with a large check is pointing at where not to look. Good answer: The credit amount, the recovery mechanism, and the net effect on total cost over the full term. Red flag: A credit presented as a discount with no explanation of how it is funded.

Question 30: What do you propose for provider-administered specialty drugs billed under the medical benefit, which this RFP does not price?

Why: Some of a plan’s most expensive drugs are billed as J-codes on the medical side, outside every guarantee in the pharmacy RFP. A proposal silent on them was priced against an incomplete picture of the plan’s drug spend. Good answer: A named approach to medical-benefit drug management, site-of-care coordination, and reporting that spans both benefits. Red flag: “Out of scope.”

Scoring the responses

Each question scored 0-3:

• 3: Specific, committed, contractually enforceable answer

• 2: Reasonable answer but lacks specificity or contractual commitment

• 1: Vague or qualified answer that avoids commitment

• 0: Non-answer, refusal, or red flag response

Total: 90 points possible. Below 50: significant concerns. 50-70: competitive but gaps exist. Above 70: strong response.

That is the full thirty-question bank with the scoring rubric. Your broker can run it alongside their standard RFP template to add a layer of specificity standard templates lack. One companion worth pairing with it: the scoring methodology itself is the most consequential design decision in the process, and our printable RFP Scoring Methodology Audit walks the three passes that catch a rubric weighted toward the wrong thing before the RFP goes out. For how the same specificity carries into the contract once a PBM is selected, see our Contract Review Readiness Checklist.

Have you evaluated PBM proposals using a structured scoring rubric? If you have a question you always ask that is not on this list, I would love to hear it. Leave a comment below.

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For the full protective contract language on pricing, rebates, audit rights, and termination provisions, see our free PBM Contract Language Library: https://www.rxbs.org/contract-language-library. Updated quarterly from patterns we see in client contract reviews.

Questions? Reach out at team@rxbs.org.

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