Glass River Analytics
Confidential sample
PBM cost and disclosure review
Harborview Manufacturing Co.
Fictional PBM: Northfield Rx Solutions. Plan year: Oct 1, 2025 to Sep 30, 2026.
Scope: pharmacy benefit contract and a 5,000-row claims extract. 4,673 claims benchmarked.
$24,391
Above contract price caps
Across 438 claims. A contract exception, not a guarantee of recovery.
$42,414
Above the NADAC benchmark
9.1% across 4,673 claims. Includes margin the contract permits, so this is not all an exception or true spread.
Section 1. Contract exceptions
Where the contract and claims differ
The $24,391 above the contract caps comes from two patterns: brand prices that did not follow a benchmark drop, and five generics priced above their caps. Those amounts are parts of the same total, not additional findings to add together.
| Drug | Type | Claims | Plan price vs. benchmark | Contract cap | Above cap |
|---|---|---|---|---|---|
| Jardiance 10 mg tablet | Brand | 30 | 1.84x | 1.06x | $7,893 |
| Eliquis 5 mg tablet | Brand | 29 | 1.80x | 1.06x | $7,157 |
| Duloxetine DR 20 mg capsule | Generic | 116 | 4.37x | 1.70x | $3,052 |
| Valacyclovir 1 gram tablet | Generic | 76 | 4.14x | 1.70x | $2,519 |
| Farxiga 5 mg tablet | Brand | 9 | 1.64x | 1.06x | $1,891 |
| Tadalafil 5 mg tablet | Generic | 37 | 5.00x | 1.70x | $831 |
| Aripiprazole 5 mg tablet | Generic | 59 | 5.25x | 1.70x | $641 |
| Quetiapine 100 mg tablet | Generic | 82 | 4.63x | 1.70x | $408 |
| Total above cap | 438 | $24,391 | |||
Separately, 25 possible duplicate payments total $4,810, pending the PBM’s confirmation. Reversed claims were matched and netted to zero with no exception.
An exception is a difference requiring review. It is not a legal conclusion or an allegation of wrongdoing.
Section 2. Reference comparison only
A separate view of generic prices
Cost Plus Drugs’ published prices were lower on all 370 claims for the five generics above. For the other 35 generics compared, plan prices were lower on most claims. This cash-price comparison is context, not a contract test or a recommendation.
| Generic group | Claims | Claim price | Paid by members | Paid by plan | Cost Plus price | Cost Plus lower on |
|---|---|---|---|---|---|---|
| The five genericsDuloxetine, valacyclovir, tadalafil, aripiprazole, quetiapine | 370 | $12,585 | $4,332 | $8,253 | $3,087 | 370 of 370 claims |
| The other 35 generics | 2,836 | $10,115 | $10,027 | $389 | $17,082 | 82 of 2,836 claims |
| All 40 generics with a Cost Plus price | 3,206 | $22,700 | $14,359 | $8,642 | $20,169 | 452 of 3,206 claims |
This comparison works in both directions: it flags claims where a lower price may be seen, and it confirms where the plan price is already working for you. Cost Plus prices were lower on all 370 claims for the five generics. For the other 35 generics, the plan price was already at or below the reference on 2,754 of 2,836 claims.
Cost Plus prices reflect the Oct 19, 2026 price list, not each fill date. NADAC is matched to fill dates. The two references are never blended or added together.
Section 3. Could not be tested
What missing records leave unresolved
Rebate pass-through, actual pharmacy payments (and therefore true spread), administrative fees and pharmacy audit credits could not be verified without the corresponding reports and invoices. Accumulator or maximizer programs also remain unconfirmed.
Another 62 claims lacked a usable benchmark or had data problems. Corrected claims and the specialty pricing schedule would allow further testing.
A practical next step
Ask the PBM to explain the above-cap pricing, confirm possible duplicates and provide the missing records. Keep its written responses in your plan’s oversight file and review the findings with qualified ERISA counsel before acting.
Prepared by Glass River Analytics. Sample document using fictional synthetic data.
All pharmacy names, logos, and brands are property of their respective owners. Price data is collected independently for comparison and audit purposes only. Glass River Analytics LLC. is not affiliated with, endorsed by, or partnered with any of the pharmacies listed.