Why Transparent Pricing Still Feels So Rare in Workers’ Comp
Transparent pricing in workers’ comp is widely praised—almost universally, in fact. Yet when it comes time to choose it, most buyers hesitate.
Not because transparency is unproven.
Not because it doesn’t work.
But because the system has trained smart, rational leaders to be careful in ways that quietly preserve the status quo.
Opacity didn’t win in workers’ comp by being superior.
It won by being familiar.
The Comfort of “Good Enough”
Most pricing models persist because they function. Claims get paid. Networks stay intact. Reports get delivered. No alarms go off.
That absence of friction becomes its own form of validation.
Over time, “working” is confused with “working well.” And when no single stakeholder owns the full economic picture—drug cost, clinical impact, administrative drag—there’s little pressure to interrogate the model beneath the surface.
Complacency doesn’t announce itself. It blends in as professionalism.
Prudence, or Fear Wearing a Suit?
Buyers are trained to manage risk. And from that vantage point, sticking with a known PBM model can feel like the responsible choice.
Switching introduces questions:
Will this disrupt claims flow?
Will providers push back?
Will something break—and land on my desk?
These are reasonable concerns. But prudence becomes counterproductive when it only evaluates what could go wrong—and not what is already quietly going wrong.
Fear of change in workers’ comp rarely looks emotional. It looks analytical. It shows up as spreadsheets that model transition costs but ignore structural leakage.
The Switching Cost Mirage
One of the most powerful forces keeping opaque pricing in place is the belief that switching is expensive and disruptive. Sometimes it is.
But more often, buyers overestimate the one-time cost of change and underestimate the recurring cost of staying put.
What rarely gets quantified:
Time spent reconciling unclear invoices
Clinical decisions made without full cost visibility
Savings narratives that can’t be independently verified
These costs don’t arrive as a single invoice. They compound quietly—spread across departments, renewals, and years.
Opacity is not free. It’s just well-disguised.
The Benefits We Discount
Transparent pricing doesn’t just clarify what you pay. It clarifies how decisions get made.
When pricing is explicit:
Clinical conversations sharpen
Accountability increases
Reporting becomes usable, not ceremonial
But these downstream benefits don’t always show up in year-one ROI calculations. They show up in governance, trust, and speed of decision-making.
Systems built to minimize disruption tend to discount benefits that arrive later—even when those benefits fundamentally change how the organization operates.
Why Transparency Feels Risky (and Why It Isn’t)
Transparency feels disruptive because it removes ambiguity—and ambiguity has been doing a lot of quiet work.
It cushions difficult conversations.
It spreads responsibility thin enough that no one feels fully exposed.
It allows “net savings” to substitute for verifiable math.
But when pricing is truly transparent, something unexpected happens: complexity decreases.
Fewer explanations are needed.
Fewer exceptions are negotiated.
Fewer assumptions are carried forward unchallenged.
Organizations that move toward transparent PBM models don’t experience chaos—they experience compression. Decisions get faster because the facts are visible.
This is where solutions like Prodigy differentiate quietly but meaningfully—not by promising perfection, but by removing the fog that forces buyers to operate on trust alone.
Ask Yourself
If transparent pricing is so clearly aligned with fiduciary responsibility, the real question isn’t why it’s rare.
It’s this:
Which risks are you actively managing—and which ones have you simply grown used to?
Are you protecting your organization from disruption, or from clarity?
And if you had full visibility tomorrow, which decisions would you make differently?
Transparent pricing doesn’t demand recklessness. It demands honesty.
And in workers’ comp, honesty isn’t radical—it’s overdue.
The prescription for performance isn’t bravado. It’s the discipline to see clearly—and the prudence to act on it. Get in touch, let’s talk.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO, Del Doherty, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management. No fluff. No spin. Just insight that pays off.
The Top 3 Comp Pharmacy Trends That Will Actually Matter in 2026
P4P #1 — Resetting the Board for 2026
Every year starts with predictions. Most of them are polite. Most of them are safe. Most of them age poorly.
This isn’t that.
This is Prescription for Performance #1 for 2026—written for leaders who actually have to make decisions, explain them, and live with the downstream consequences.
If 2024 and 2025 were about awareness, 2026 is about enforcement—by regulators, by cities, and increasingly by buyers themselves.
Here are the three trends that will define comp pharmacy this year, whether the industry is ready or not.
1. Transparency Is No Longer Optional—and It Can’t Be Retrofitted
Let’s start with the obvious one—because it’s no longer theoretical. Transparency is now being demanded, enforced, and litigated.
Federal lawsuits against the largest PBMs have pulled back the curtain on unfair pricing, rebate games, and conflicted incentives. At the same time, cities and public entities are passing their own transparency and audit requirements, forcing PBMs to explain—not just report—how money actually moves.
Here’s the part the industry doesn’t like to say out loud:
You can’t bolt transparency onto a business model that depends on opacity.
The largest PBMs were not designed for clarity.
They were designed for scale, leverage, and complexity.
And complexity is a terrible place to hide when:
Regulators are asking second and third questions
Cities want audit rights written into contracts
Public buyers have to defend decisions in open meetings
This is why transparency initiatives from legacy incumbents often feel performative:
More dashboards
More reports
More “trust us” language
But very little structural change.
PBMs built differently—like Prodigy—don’t have to retrofit transparency. It’s native to the model. When incentives are aligned and economics are straightforward, transparency isn’t a risk—it’s a strength.
2026 reality: Transparency is no longer a differentiator. It’s a gate. And some PBMs simply won’t fit through it.
2. Specialty Drugs Are the Fastest-Growing Force in Workers’ Comp—and Discounts Won’t Save You.
Specialty drugs are no longer “emerging” in workers’ comp. They’re here—and accelerating.
Driven by:
A robust FDA specialty pipeline
Expanded presumptive coverage laws
Increased use of biologics, injectables, and infused therapies
Specialty is now the fastest-growing segment of comp pharmacy spend. And yet, many strategies still revolve around one tired idea: “Can we get a better discount?”
That mindset misses the point.
In workers’ comp, specialty cost isn’t driven primarily by unit price. It’s driven by:
Clinical appropriateness
Timing of care
Site of care
Duration of care
Whether the therapy actually matches the condition
We’ve already covered this in prior P4P articles—certain specialty drugs and conditions consistently drive outsized claim impact. The lesson hasn’t changed, but the stakes have.
The winning strategy in 2026 goes beyond discounts and asks:
Moving from transaction review to clinical pathway design
Shifting focus from “Is this allowed?” to “Is this appropriate now?”
Treating specialty as a care strategy, not a billing anomaly
This is where models like Specialty Nexus matter—not just as a carve-out, but as an operating layer that brings clinical governance to specialty spend.
2026 reality: If your specialty strategy stops at pricing, you don’t have a strategy—you have exposure.
3. The PBM Model Itself Is Under Scrutiny—and Fiduciary Discipline Is the New Standard.
At this point, every PBM should have gotten the memo. This is the hardest conversation—and the most important.
The traditional PBM model is being questioned not because it’s unpopular, but because it’s indefensible under scrutiny.
For years, the industry normalized practices that would never survive a fiduciary lens:
Wonky pricing hidden behind “network guarantees”
Rebates disconnected from clinical decisions
Formularies influenced by economics no one wants to explain
As prior P4P articles have called out: these aren’t edge cases. They’re structural features of legacy PBM design.
In 2026, that matters—because buyers are changing how they evaluate partners. The new questions sound like:
Who is this PBM actually working for?
Where do incentives sit?
Can this model withstand an audit, a regulator, or a public hearing?
PBMs like Prodigy that operate with fiduciary discipline, clean economics, and explicit controls don’t fear these questions. They welcome them. Others will spend the year managing narratives instead of outcomes.
2026 reality: The PBM model is no longer judged by promised savings—but by whether it can survive daylight.
The Throughline for 2026
These aren’t three separate trends. They’re one story.
Transparency pressures expose weak models.
Specialty growth amplifies clinical risk.
And legacy PBM economics struggle to justify under scrutiny.
2026 will reward leaders who:
Choose partners built for scrutiny, not scale alone
Treat specialty as a clinical challenge, not a pricing exercise
Demand fiduciary clarity instead of accepting industry norms
The comp pharmacy system isn’t collapsing. It’s being forced to grow up.
And as always, performance follows design.
Transparency isn’t coming—it’s here. Specialty isn’t slowing. And PBM models are being tested in public. In 2026, leaders will design outcomes. Everyone else will explain them. Let’s schedule time to plan your 2026.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO, Del Doherty, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management. No fluff. No spin. Just insight that pays off.
Transparency Theatre
For years, the industry treated transparency like theatre—an applause line, not a business model. Some PBMs dimmed the lights, shuffled a few set pieces, and insisted the stage had changed.
But the audience isn’t buying it anymore.
Workers’ comp payers are asking harder questions.
New delivery models are emerging.
Payers are being forced to do more with less, even as cost, complexity, and clinical risk accelerate.
And underneath it all, a truth the industry has tried to outrun is finally catching up:
You can’t retrofit transparency into a PBM business model built on secrecy and opacity.
The economics don’t work. The workflows don’t align. And the technology simply wasn’t designed for the world that now exists.
The Industry’s Strategic Moment
This isn’t a wake-up call. It’s a restructuring of the entire ecosystem.
Employers want pharmacy program designs that actually work for their injured workers—not the illusion of choice inside a locked box.
Workers’ comp payers want treatment pathways that reduce friction, improve return-to-work, and eliminate unnecessary spend.
Meanwhile, incumbents keep trying to repaint the walls of a house sinking into its own foundation.
Gaslighting payers cannot solve this. Transformation can.
We Built Prodigy for This Moment
Prodigy wasn’t built to survive the old world.
Prodigy was built to replace it.
While others built on the status quo, we chased architectural readiness.
While others relied on rebates to fill margin gaps, we built a model where value creation didn’t require hiding the true cost of care behind a curtain.
And while legacy PBMs stitched together siloed workflows to promote opacity, we designed unified process—with real-time visibility that unlocks:
Smarter and faster decision-making
Seamless patient experience
Payer flexibility and customization
True transparency
It’s what employers have needed.
It’s what payers have been waiting for.
And it’s what legacy systems simply cannot retrofit into their DNA.
This isn’t speculation. It’s design. The status quo was never going to carry the industry into its next era.
The Market Has Spoken
The next decade will be defined by leaders who embrace three truths:
Transparency is not a feature—it is a foundation.
You cannot layer it onto a model architected for opacity.
Anything less is a costly delay tactic.Fiduciary responsibility is no longer optional.
Payers can’t outsource judgment to vendors with misaligned economics and incentives.Care only works when the patient is the center of gravity.
The moment the system forgets that, costs rise, outcomes fall, and friction multiplies. Put the patient first, and everything else finally falls into place.
The payers that evolve will succeed. Everyone else will see mediocre outcomes or worse.
If you’re shaping your 2025–2026 strategy, here’s what leaders are doing next:
Rebuilding pharmacy programs around transparency + intelligence
Moving aways from PBMs with business models dependent over-reliant on rebate-driven economics.
Prioritizing systems that lower friction for adjusters, nurses, and members
Partnering with platforms/partners (like Prodigy) designed for transformation—not preservation
If you’re ready to move beyond transparency theater, and would like to explore what this transition looks like for your organization, I’d be happy to help you map it.
The market is moving. The question is who’s moving with it. Let’s schedule time to experience full transparency at scale.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO, Del Doherty, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management. No fluff. No spin. Just insight that pays off.
Why Big PBMs Can’t Offer Transparency at Scale
You can’t retrofit transparency into a PBM business model built on secrecy and opacity.
Trying to retrofit transparency into a legacy PBM is like bolting windows onto a submarine—at best, you get a brief view; at worst, you sink the vessel.
Transparency sounds simple, but it is operationally incompatible with business models built on opacity. Everyone wants the credit for being “open,” yet few can afford what openness really costs.
The Transparency Paradox
Large PBMs—and several mid-market ones—publicly praise transparency while their financials depend on keeping it partial. The contradiction is structural: these entities are publicly traded, with earnings expectations tied to rebate retention, spread pricing, and network differentials.
According to industry filings, retained rebates (including PBM GPO and data access fees) and spreads represent 25–40% of gross margins for the top three PBMs (GAO, 2024; SEC, 2023). Those margins are not side effects; they are the business model. Full transparency would flatten those profits and immediately hit forward-looking earnings—something no public PBM management can tolerate.
The result is what we at Prodigy call the Transparency Theater: partial disclosures, selective data access, and clever contract language that implies honesty while preserving the status quo.
Cultural and Operational Inertia
Transparency isn’t a software toggle—it’s a cultural rewiring. It demands changing how people are trained, how systems are built, and how incentives are paid.
Legacy PBMs reward teams for maximizing retained revenue; their infrastructure was engineered for opacity. You can’t ask an organization to show all its cards when the dealer’s bonus depends on what stays hidden.
Why Scale Breaks Transparency
Transparency doesn’t scale when your infrastructure profits from confusion.
Real transparency requires synchronized data across claims, rebates, and network contracts—essentially a real-time, audit-ready ledger. For a billion-claim processor, that’s not a modernization effort; it’s an existential threat.
Prodigy’s Embedded Transparency
At Prodigy, transparency isn’t a retrofit—it’s the foundation. It’s a core part of our ethos — in words, in action and in software code. Transparency is part of our operating system for trust—built so every claim, rebate, and fee is visible in real time. No tiers of visibility. No selective disclosure. No “trust us” clauses. Our clients see exactly what we see—because trust scales only when visibility does.
Our Challenge to the Industry
Transparency cannot be modularized. You can’t graft integrity onto infrastructure optimized for arbitrage.
Ask your PBM one question:
Would your transparency survive an independent audit—without excuses, redactions, or NDAs?
Real transparency doesn’t need stage lights. It needs courage, clean code, and a culture that doesn’t flinch when the curtains lift. We built Prodigy to do just that — make transparency operational, not aspirational. Because when visibility is native, accountability becomes second nature.
If you’re ready to move beyond transparency theater, we’d love to show you what real visibility looks like in practice. Let’s schedule a short demo to experience full transparency at scale.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO, Del Doherty, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management. No fluff. No spin. Just insight that pays off.
3 Excuses PBMs Use to Keep Your Rebates — And Why They’re Bogus
The cost of drugs has become America’s quiet scandal—skyrocketing expenses wrapped in layers of complexity that only benefit those controlling the middle. As state and federal regulators tighten the vise on transparency, one truth keeps surfacing: rebates are the soft underbelly of the PBM model. They were meant to lower costs, but for many payers, they’ve become the black box where savings disappear. The irony? The data exists, the dollars exist, and the excuses don’t hold up under daylight..
Excuse #1: “They’re Baked Into Your Pricing.”
It sounds neat, logical—even generous. Your PBM claims you’re already benefiting from rebates through lower upfront drug costs or discounted AWP. But peel back the label, and you’ll find that “baked in” means you’re paying for the ingredients, but someone else is eating the cake.
Key Point: “If rebates were truly baked into pricing, every PBM’s price should rise and fall with the manufacturer’s rebate cycle. They don’t.”
At Prodigy, we’ve tested this myth. Over and over, we’ve provided equal or better pricing and passed rebates back to our clients. The numbers don’t lie—rebates can coexist with competitive rates when transparency is real. When they’re not, someone’s pocketing the spread.
Excuse #2: “Rebates Are Hard to Reconcile Back to Your Claims.”
Here’s the PBM equivalent of the “it’s complicated” relationship status. They’ll tell you the timing doesn’t align: the claim might be closed, the patient stopped taking the medication, or the reconciliation could create extra administrative work. Quite convenient.
Key Point: “Complexity is the oldest refuge of the unaccountable. Don’t settle for mediocre.”
Every system is designed to produce the exact result it produces. If rebates are slow, opaque, and hard to match back to claims, that’s not an accident—it’s by design. The status quo benefits the PBM, not the payer. At Prodigy, we rewired the system to do what it should do: trace every dollar, align timing, and make reporting as clean as the claim itself.
Excuse #3: “Rebates Don’t Exist—Or They’re Too Small to Matter.”
This one’s almost impressive in its audacity. PBMs argue that rebates are negligible, or don’t apply to your formulary mix. The reality? Most brand drugs—specialty or not—generate rebates. Federal and state laws reference them. Even the White House has taken aim at rebate opacity through executive orders.
Key Point: “When someone tells you rebates don’t exist, ask them why laws keep being written about them.”
Across our clients, rebates often represent hundreds of thousands of recoverable dollars annually—money that can fund better patient programs, technology investments, or direct cost savings. Saying they’re negligible is like saying gravity is optional. You can ignore it, but it’s still pulling on your wallet.
The Simple Truth
When you strip away the excuses, the logic circles back to one clean answer:
“Occam’s Razor: the simplest explanation is that they’re keeping them.”
If rebates don’t flow to you, they flow somewhere. PBMs have built an infrastructure that normalizes opacity under the guise of convenience. But make no mistake—what’s convenient for them is costly for you.
Rewiring the System
At Prodigy, we designed our model around radical transparency. We don’t bury rebates under pricing, defer them in reconciliation purgatory, or pretend they don’t exist. We show them. We share them. We make them make sense. Because in a system that’s been designed to obscure, clarity is the most disruptive act of all.
If your PBM can’t show you exactly where your rebates go, you already know the answer. It’s time to stop accepting complexity as destiny.
Prodigy is rewiring the entire system—one honest dollar at a time. Don’t let your PBM spin the story—”Rebates” and “Competitive Price” are not mutually exclusive.
If you’re ready to take action, let’s talk. Let us benchmark your program—category by category—and show you exactly what you should be getting back.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Drug Rebates: The Money You’re Leaving on the Table
Imagine buying a new car and the dealer quietly pockets the manufacturer’s rebate instead of passing it to you. And you are stuck paying full price (MSRP) for the car. Yikes. That’s exactly what’s happening in pharmacy benefits when your PBM keeps rebates—or worse, tells you the rebates are “already baked into the price.”
Here’s the truth: if you’re not receiving rebates, you’re not just being left behind—you may be getting taken advantage of.
Prodigy has proven time and again that we can deliver competitive—or better—pricing while also disclosing and sharing rebates from manufacturers. Rebates aren’t a side perk; they are a core source of savings, especially on high-cost and specialty drugs.
Where Rebates Really Live
The myth in workers’ compensation is that rebates are rare. The reality? Most brand drugs—specialty or not—are eligible for rebates. Let’s spotlight a few categories straight from our rebate data:
Oncology (Cancer Therapies): Drugs like Keytruda (immunotherapy) and Abraxane (chemotherapy) often carry meaningful rebates, even though they sit at the top of your spend chart.
Hematology & Blood Disorders: Products for sickle cell disease and hemophilia may look like “must-pay, no-choice” categories—but rebates exist here too.
Ophthalmology: Eye-care drugs for diabetic macular edema and dry eye disease come with rebate opportunities most payers never see.
Dermatology: From alopecia treatments to blockbuster biologics like Olumiant, dermatology has become a hidden rebate minefield.
Mental Health & Women’s Health: Even drugs for substance use disorder (Sublocade, Vivitrol) and contraceptives (Mirena, Kyleena) can be rebatable.
This isn’t theory. These are real, category-wide rebate dollars flowing through the system. If you’re not seeing them, ask yourself—where are they going?
Don’t Just Take Our Word for It
Rebates aren’t some Prodigy invention. State laws across the country and even a presidential executive order on drug pricing have specifically targeted rebate transparency. Why? Because regulators know it’s one of the biggest pressure points in pharmacy costs.
If lawmakers think it’s worth policing, shouldn’t payers make sure they’re not missing out?
The Easy Decision
Rebates shouldn’t be controversial. They’re your dollars, generated by your claims. You deserve to see them, measure them, and keep them.
At Prodigy, we don’t play the “baked into pricing” shell game. We give you competitive or better pricing AND your rebates—in some cases, every penny.
Final Word
If you’re not receiving rebates, you are getting left behind. Don’t let your PBM spin the story—”Rebates” and “Competitive Price” are not mutually exclusive. In today’s market, this isn’t a “nice to have.” It’s a performance must-have.
If you’re ready to take action, let’s talk. Let us benchmark your program—category by category—and show you exactly what you should be getting back.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Reconnecting With Your Why.
The Forgotten Why
In workers’ comp, it’s easy to get caught up in the mechanics: claims in, bills out, discounts tracked, reports generated. But if that’s all your PBM is doing, they’re missing the mark. Pharmacy benefits aren’t about transactions—they’re about people. Injured workers. Patients trying to get their lives back. Families depending on a system that often feels like a maze. Your team in the front lines making all of this work.
Too many PBMs have turned the job into a commodity, measuring success by how many fills they can process or how quickly a claim gets paid. That’s not a “why.” That’s a “what.” And when your PBM’s “what” isn’t connected to your “why,” you’re left with misalignment, waste, and frustration.
Finding Your Why
Your “why” is the anchor. For claims executives and risk managers, it’s not just about savings. It’s about ensuring the right medication, at the right time, for the right reason—without unnecessary friction.
When you start with your “why”:
The who becomes clear—partners that share your values rise to the top.
The what becomes sharper—programs, controls, and clinical oversight are no longer abstract; they’re purposeful.
The future becomes possible—because you’re no longer measuring success by transaction volume but by patient recovery and systemic clarity.
The PBM That Serves Your Why
The PBM that serves your why isn’t a claims processor. It’s a guidepost back to your purpose.
From billing to belonging: Moving past “discounts and deals” into true alignment with payer goals.
From opaque to open: Transparent pricing and clinical clarity that reconnect decisions to outcomes.
From reactive to reflective: Instead of chasing problems, designing programs that reduce complexity before it starts.
At Prodigy, our “why” is simple: to help patients recover faster, safer, and smarter—while giving payers clarity and confidence in a space known for confusion and equivocation. We exist to make the process simpler, the outcomes stronger, and the noise disappear.
A Final Word
If your PBM doesn’t connect you to your “why,” then you don’t have a partner—you have a vendor. And if you can’t articulate your “why,” then it’s time to pause, rethink, and realign.
Because when you know your why, the who and the what become clear.
If you’re ready to realign your PBM with your purpose, let’s talk. Prodigy helps payers and claims leaders rediscover their why—and turn it into measurable outcomes.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Summer Postcards from the Edge of the PBM World
Vacation mode: activated. Strategic thinking: still on.
Even when you step away from the screen and slow down, the world has a way of whispering lessons—if you're listening. On a recent getaway, between good food and better sunsets, I couldn’t help but notice how everyday moments mirrored the very things we talk about in workers’ comp pharmacy management.
So instead of skipping this edition of P4P entirely, I’m sending you a few strategic postcards from the road. Each one is a bite-sized reminder of the traps to avoid—and the clarity that still wins.
🏖️ Postcard #1 – From the Beach: The Illusion of “All-Inclusive”
“Lying on a resort beach that promised ‘all-inclusive’—except for chairs, towels, drinks, and the air I breathe. Sound familiar? Legacy PBMs love this game. Always read the fine print.”
We’ve all been sold the dream. But when the real cost shows up on the bill, the promise fades. If your PBM says “all-in,” ask what they’re leaving out.
🏞️ Postcard #2 – From the Mountains: Path Dependency
“We saw hikers blindly follow each other up the wrong trail. Made me think of payers sticking with the ‘safe’ PBM path—only to find the view (and value) disappointing.”
Comfort is a poor substitute for strategy. Just because a path is worn doesn’t mean it leads somewhere worthwhile.
🍷 Postcard #3 – From Wine Country: Brand Loyalty Blindness
“Tourists dropping $200 on a wine just because of the label. Back home, payers do the same with PBMs. If the performance is average, the brand premium is just waste.”
A fancy label doesn’t make it a better vintage. In pharmacy benefit management, brand trust should be earned—not assumed.
🛍️ Postcard #4 – From the Markets: Wolves in Sheep’s Clothing
“Every booth claimed ‘authentic local goods’—until I saw the same barcode stickers from Amazon. Lesson: flashy doesn’t mean real. A reminder for evaluating vendors, too.”
There’s a growing trend of lookalike PBMs using transparency language while hiding legacy behaviors. Scrutinize what’s under the hood.
📸 Postcard #5 – From a Tour Bus: The Cost of Comfort
“Most tourists chose the bus tour. Easier, familiar, no thinking required. But they missed the best spots. Same with pharmacy networks—comfort is expensive. Custom beats cookie-cutter.”
Customization doesn’t mean complexity—it means better outcomes. Don’t pay for ease. Pay for value.
Back Soon. But Here’s What I’ll Leave You With.
Sometimes, distance brings clarity. Whether you’re rethinking your PBM, prepping for renewals, or just trying to make smarter decisions in a noisy market—don’t wait for perfect timing. Clarity compounds.
I'll be back with new P4P insights in two weeks. Until then, if anything here hits home, drop me a note or forward this to someone who’s still drinking the brand-label wine.
Better decisions start with better questions.
Let’s ask smarter ones—together.
—Del
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Field Notes from the Frontline: 3 Pharmacy Pains Payers Can’t Ignore
Over the past few weeks, we’ve been in deep conversations with TPAs, carriers, and self-insured employers—and a pattern has emerged. Everyone’s wrestling with some version of the same headache:
→ GLP-1s sneaking into claims
→ Physician dispensing bypassing oversight
→ And PBM “transparency” that feels anything but clear.
In this week’s P4P, we’re cutting through the noise. No fluff, no spin—just the top 3 pharmacy pain points facing workers’ comp payers right now, and smarter ways to fix them.
Because when the fog clears, so does performance.
⸻
1. GLP-1s Are the Canary in the Coal Mine
Once a whisper, now a roar—GLP-1s like Ozempic and Wegovy are flooding into comp claims, often without supporting documentation, outcomes monitoring, or long-term cost plans. They’re not the only specialty drug making noise—but they’re a warning shot.
✅ The Fix:
Layer in pre-approval checkpoints for high-cost therapies. Build a clinical approval framework that doesn’t just say yes or no—but asks why, when, and for how long. Combine that with longitudinal monitoring to stop passive approvals from becoming long-term liabilities.
2. Physician Dispensing Sidesteps the Playbook
Despite formulary rules and networks, physician dispensing remains a costly loophole. It inflates spend, undermines safeguards, and often escapes audit trails.
✅ The Fix:
Deploy real-time clinical edits with custom business rules—ones that flag physician-dispensed meds automatically for review or rejection. Partner with your PBM to maintain a strict default posture grounded in statute. It’s not about policing—it’s about protecting.
3. Transparency Talk, Vendor Walk
Many payers still don’t know what they’re actually paying for—or where the dollars go. Rebate math is fuzzy. AWP discounts are inflated. “Pass-through” often passes over critical context.
✅ The Fix:
Move beyond buzzwords. Demand line-item clarity on pricing, rebate logic, and service fees. Require MAC list visibility. Push for contracts with auditable definitions—not vague assurances. If a PBM can’t show you exactly how it makes money, you’re the product.
Final Dose
Most of the challenges in workers’ comp pharmacy aren’t unsolvable—they’re just untreated. Payers don’t need a new strategy. They need a true partner who can see the red flags before the bill hits the system and tailor solutions to fit their risk, population, and workflow. That’s what Prodigy was built for.
Better decisions start with better questions.
Let’s ask smarter ones—together.
📞 Let’s talk. If you’re ready to trade volume for value, and autopilot for actual oversight, Prodigy is ready to show you what real care looks like. Call me for a virtual consult. No pressure. Just clarity. I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
PBM Mirage
When Volume Poses as Value
Let’s call it what it is.
For too many PBMs, “pharmacy benefit management” has become a misnomer. They don’t manage pharmacy benefits—they manage fills. They don’t guide care—they automate approvals. And the endgame isn’t better outcomes—it’s faster fills, higher volume, and margin on the move.
It’s not care. It’s commerce—disguised in acronyms.
This is the fill-and-bill industrial complex, where injured workers become units of throughput, and clinical nuance is paved over by protocols written to prioritize profit.
At Prodigy, we’ve seen it up close:
Formularies that push brand-name drugs with rebates, not outcomes
Mail order programs that reward speed over scrutiny
“Clinical programs” that are just glorified prior auth queues
Meanwhile, patients with polypharmacy risks, behavioral health flags, or complex comorbidities are run through templated workflows—zeroing out what actually matters: clinical intervention.
At Prodigy, we do it differently:
✅ Our pharmacists aren’t hidden behind policies—they’re embedded in every complex case
✅ We flag risky combinations and step in early—before costs explode
✅ We call physicians directly, provide evidence-based alternatives, and track outcomes post-intervention
✅ We don't just audit prescriptions—we own clinical performance
Because the real job isn’t filling scripts—it’s preventing the wrong ones, adjusting the risky ones, and advocating for what’s best for the patient.
Here are three ways to tell if your PBM is just pushing pills under the guise of management:
Do they intervene—or just authorize?
If clinical review takes less time than brewing coffee, it’s not review. It’s rubber-stamping.Do you know which patients were actually helped?
Or just how many were processed?Do your pharmacists lead—or follow the script?
Because if tech teams are setting your clinical policy, don’t expect care—expect compliance theater.
Pharmacy benefit management isn’t about throughput. It’s about thoughtfulness, helping payers and improving patient outcomes.
📞 Let’s talk. If you’re ready to trade volume for value, and autopilot for actual oversight, Prodigy is ready to show you what real care looks like. Call me for a virtual consult. No pressure. Just clarity. I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Brand Loyalty or Blind Faith?
Familiar Names. Hidden Risks.
We get it. The big names feel safe. They’ve been around forever. You know the reps. The deck looks good. The reports feel “familiar.”
But let’s be blunt—familiarity is not protection. In the PBM world, it’s often the perfect camouflage.
The big three PBMs? They're not just legacy players—they're legacy liabilities. They’re currently under federal investigation. They’ve been linked to executive orders targeting drug pricing practices. And yet, many payers keep renewing—often on autopilot—because the brand feels easier than the unknown.
That ease comes at a cost.
Behind the brand loyalty, we’ve seen:
Contracts built a decade ago still quietly driving decisions
Formularies bloated with margin-fattening drugs
Spread pricing embedded in layers of complexity
"Custom reports" that show exactly what they want you to see—and nothing more
Here’s the risk no one talks about: sticking with legacy logos can expose you to scrutiny—scrutiny you didn’t invite but may be forced to answer for. When your PBM ends up in the headlines, what’s your defense?
Three ways to test if your “trusted” partner is quietly eroding trust:
Would you pick them again if starting fresh today?
If not, you’re paying the nostalgia tax.Does your pricing model still hold up under scrutiny?
Or is it just a pile of spreadsheets and handshakes?Is your PBM aligned to your goals—or just leveraging your loyalty?
When things go wrong, do they act like a partner or a PR firm?
At Prodigy, we’ve helped payers carve out of these relationships without chaos. No fire, no fury—just a smarter hedge that reduces risk and restores control.
Because in this market, brand loyalty isn’t just expensive—it’s dangerous.
Ask yourself:
Is your PBM implicated—directly or indirectly—in investigations around pricing abuse or their role in the opioid epidemic?
(Hint: If they’re one of the Big Three, the answer may already be yes.)
Are you getting the same level of service, access, and strategic attention as their biggest book of business?
Or are you just a line item behind a firewall of policy?Do you feel like a third wheel—locked in a lopsided relationship you can’t seem to shake?
If so, ask yourself: who’s really benefiting from your loyalty?
📞 Let’s talk. There’s a smarter way forward—and it starts with asking better questions. Call me for a virtual consult. No pressure. Just clarity. I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Wolves in Sheep’s Clothing
Transparency Talkers, Accountability Dodgers
Isn’t it rich? The same PBMs that spent years pillaging payer budgets now parade around as prophets of transparency—shouting “clarity” from the rooftops like they just discovered sunlight.
But beware the rebrand. Today’s PBM landscape is full of “transparency” models that are anything but. There are shades of openness, gradients of clarity, and just enough polish to pass as progress.
Here’s the truth: some PBMs have learned to talk the talk, but what they’re offering is a distinction without a difference. The costume has changed, but the playbook hasn’t.
So how do you know if your PBM is just putting on a show?
Here are three tests to separate the real from the rehearsed:
Do you know—really know—your true program costs?
Not averages. Not anecdotes. Actual, all-in, claim-by-claim cost visibility.Do you have access to raw, unfiltered data?
Not scrubbed reports or dashboards designed for optics. The truth is in the raw feed.Is your PBM acting like a real partner—or a vendor with a thesaurus?
Do they solve problems or just explain them away?
— ALWAYS READ THE FINE PRINT!
Forget the glossy portals and the polished pitch decks. At Prodigy, we believe transparency isn't something you perform—it’s something you prove.
We put our stake in the ground. Whether it’s turnaround time, clinical outreach, financial guarantees, or real-time reporting, we build accountability into every contract with SLAs and performance guarantees. No fluff. Just stakes, skin, and standards.
Ask yourself:
Does your PBM have skin in the game?
Can you hold them accountable in writing?
Are you actually satisfied with the status quo?
If you hesitated—or said no—to any of these, it might be time to explore a smarter alternative.
📞 Call me for a virtual consult. No pressure. Just clarity.
I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
Hedge Your Bet, Don’t Burn the Bridge
April is over and Q2 is now in full swing.
You’re back in rhythm. Revisiting old conversations. Following up on open loops. Asking your team the question you tabled weeks ago: “How’s our PBM doing?”
The answer? It’s not chaos. But it’s not confidence either.
The numbers aren’t glaring. The outcomes aren’t awful. But the updates come with a raised eyebrow, a hesitant “well…”—the kind of feedback that doesn’t ring alarms but still lingers in the gut.
You’re not regretting the decision. But you are re-evaluating the bet.
The Quiet Dilemma
As an executive, you were instrumental in selecting your PBM or ancillary partner. You did the diligence. You saw the deck. And at the time, the hand looked promising.
But leadership isn’t about making the perfect call—it’s about knowing when to adjust before the table turns cold.
That’s where hedging comes in.
Hedging isn’t a panic play. It’s a proactive posture.
It’s not walking away—it’s widening the aperture. Think of it as trimming the hedges while the garden still looks good. You’re not replacing the foundation; you’re reinforcing the fault lines.
At Prodigy, this is our specialty. Clients don’t have to ditch their PBMs—they carve out the riskiest, costliest corners:
Specialty medications that account for 1-2% of scripts but 20%+ of total drug spend
Catastrophic claims where oversight matters most
Challenging geographies with spotty vendor performance
These areas get moved into our clinically-driven model—with real-time reviews, evidence-based protocols, and unmatched specialty insight—while your traditional meds stay right where they are.
You stay in control. You gain visibility.
And most importantly—you stay ahead.
Hedging, Done Right, Does Three Things:
1. Protects Without Provoking
Why gamble on a full transition when you can surgically target the outliers? Specialty carve-outs let you pressure-test smarter models without unnecessary friction.
2. Reveals What’s Really Under the Hood
You know what your PBM reports. But what are they missing? Our team applies 50+ clinical and claims endpoints to identify misaligned drugs, wasteful dosing, off-label drift, and hidden high-cost risks.
3. Keeps You in the Driver’s Seat
Hedging gives you leverage without litigation. It nudges your incumbent to improve while giving you a runway to build a smarter model over time.
So if Q2 has you sensing some slippage—or if your gut says “we can do better”—you’re not alone.
You don’t have to start from scratch.
You just have to start hedging with purpose.
Bottom Line:
Not ready to replace your PBM? No problem. You can hedge your bet by carving out high-risk, high-cost areas—like specialty drugs or catastrophic claims—without disrupting your entire program. Prodigy helps clients layer in clinical precision where it matters most, giving you more control, better oversight, and real savings—without rolling the dice.
Let’s talk. We’ll help you turn second thoughts into first-mover advantage.
Growth Vs. Fixed Mindset: What’s Driving Your PBM Decisions?
Hey, there!
Let’s be real—when it comes to picking a PBM, most decisions aren’t purely analytical. Behind every spreadsheet, rebate guarantee, and network slide lies a quiet, powerful force: mindset.
Some leaders look at a half-full glass and ask how to top it off. Others see a half-empty one and slam on a lid. That’s the fundamental difference between a growth mindset and a fixed mindset—and it shows up loud and clear in PBM decision-making.
What are the hidden costs of this decision? Lost savings, reduced flexibility, growing dissatisfaction, and poor patient outcomes slipping through your fingers every day you choose the status quo.quo?
Let’s Dive In!
On the surface, PBM choices are about savings, discounts, and access. But scratch a little deeper, and the real question comes into focus: “Are we trying to make things better, or just trying not to make them worse?”
Let’s talk about GLP-1s for example. When Prodigy predicted the impact of these meds—Ozempic, Wegovy, Mounjaro—in the Workers’ Comp space, some folks reacted with raised eyebrows: "That’s a stretch," or "Way too expensive." [Read article]. That was classic, instinctive fixed mindset response. But growth-minded leaders? They asked the right questions and saw the possibilities — faster recoveries, fewer complications, and workers getting back on their feet sooner. Same therapy. Different lens. Very different outcome.
When Fixed Mindset Takes the Wheel
A fixed mindset doesn’t just make you cautious—it can lead you straight into confirmation bias. Once you decide “change is risky,” your brain starts ignoring anything that suggests otherwise. You seek out familiar reports, lean on legacy consultants, and choose vendors who’ve always told you what you wanted to hear. We covered this before, if you keep your feedback loop small, don’t expect big breakthroughs.
Firefighting Vs. Future-Proofing
Fixed-minded leaders spend their days reacting—chasing audits, patching leaks, negotiating Band-Aids. Growth-minded leaders shift gears. They design systems that prevent the fires in the first place.
In prior posts we explored how great leaders tune out distractions to focus on what really matters. That applies here too: picking a PBM isn’t just about chasing today’s rebates and discounts. It’s about future-proofing and building a smarter pharmacy strategy that will excel next year—and five years from now. Every month you delay the switch, you risk losing your ability to future-proof your pharmacy program.
Spotting A Growth Mindset in Your PBM Strategy irefighting
So how do you know if your team’s leading with a growth lens? Here are the signs:
You want transparency. Not just a big number—but clarity on how that number works.
You embrace innovation. You’re not afraid of new therapies—you ask what they make possible.
You think beyond the quarter. You make moves today that pay off tomorrow.
You value clinicians . Clinical leadership isn’t just welcome—it’s essential.
Gut Check: Fear or Vision
Every PBM decision is a mirror. It reflects what you truly believe: Are you trying to avoid risk, or create value?
We’ve seen both sides. Fixed mindset thinkers cling to legacy models, even when those models are quietly leaking value. Growth-minded leaders flip the script. They partner with innovators like Prodigy—and unlock data, visibility, and clinical outcomes they never thought possible. It’s not reckless. It’s just bold.
Bottom Line:
Let’s stop pretending PBM selection is just about procurement. It’s about leadership. So ask yourself: Are you playing not to lose? Or are you playing to win?
Because the future belongs to leaders with a growth mindset who don’t just settle for what’s in the glass. They ask for the pitcher.
Are you a growth-minded leader or a fixed mindset thinker?
Let’s chat.
Opportunity Costs
Hey, again!
On my last message, we talked about doing the right math. But doing the math often means facing a decision point that requires a clear analysis of both the benefits of change and the opportunity costs of staying put. It’s easy to focus on potential switching costs —implementation headaches, short-term disruptions, and effort—but what about the cost of inertia? What about the dollars, flexibility, satisfaction and patient outcomes slipping through your fingers every day you choose the status quo?
Let’s Dive In!
Imagine you're standing at a crossroads. One path leads to a modern, optimized pharmacy benefits model (Prodigy)—cost control, transparency, and better outcomes. The other? A well-worn trail of escalating costs, hidden fees, and misaligned incentives. The only problem? Many payers are frozen at the fork, afraid to move. Read article on sunk cost fallacy.
But here’s the reality: Not switching your PBM isn’t a neutral decision—it’s an expensive one. It’s like refusing to upgrade from dial-up internet to high-speed fiber because "the old way still works.” Meanwhile, your competitors are streaming in 4K while you're stuck buffering, losing time, efficiency, and cost savings with every passing moment.
Let’s talk about the opportunity cost of staying put.
Hidden Fees (The Slow Leak in the Boat)
Many legacy PBMs operate like old insurance policies—you think you’re covered, but the fine print is bleeding you dry. Spread pricing, rebate traps, and arbitrary markups siphon money out of your plan. Staying with a legacy PBM is like patching up a sinking boat with duct tape while watching competitors sail past with high-performance engines. Every month you delay switching, you’re funding someone gross margin.
The Cost of Inflexibility (The Rusted Lock on the Toolbox)
Innovative PBM models offer dynamic pricing, cost-plus agreements, and real-time data transparency. But if you stick with a rigid, outdated PBM, you’re effectively locking your toolbox and throwing away the key. They limit your ability to adapt to market shifts, new therapies, and employer demands. In the dynamic pharmacy landscape of the future, agility wins. Standing still? That’s just slow-motion failure.
The Patient Experience Cost (The Slow Lane of Healthcare)
Every payer talks about patient outcomes, but an opaque, old school PBM operating model puts profits ahead of patients.That means higher payer costs, restricted access, and unnecessary barriers to care. Imagine running a rideshare company but forcing passengers to take the longest, most expensive route every time. It takes longer and costs more. That’s what sticking with the wrong PBM feels like for patients (and payers alike). A smarter, more aligned PBM puts the patient in the fast lane—with cost-effective, clinically appropriate access to care.
The Fork in the Road
We’ve talked before about fuzzy logic how decisions—or indecisions—can sabotage your program success and how leaders get trapped in the sunk-cost fallacy. This is one of those moments. The cost of switching PBMs may feel daunting, but the cost of inaction is worse. Every day you delay, you’re leaving money, flexibility, and patient trust on the table.
The best leaders know when to pivot. Are you ready to make the right turn?
Bottom Line:
Escaping the status quo isn’t just about making a change—it’s about making a smarter move. If you have any doubts, let’s take five minutes to do the right math on your switching costs vs the opportunity costs of staying keeping your current PBM. As I have said before, if you don’t walk away with valuable insights, the next coffee’s on me. But if I’m right, you’ll be one step closer to cutting through the noise and making a decision that will have your whole team thanking you.
Let’s chat.
Do The (Right) Math
Hey, there!
Most leaders believe they’re making data-driven decisions on PBMs and ancillary programs, but they’re solving the wrong equation. Activity math—rebates, discounts, fancy marketing and flashy dashboards—masks the real impact. True impact means doing the right math: solving for net costs, long-term patient outcomes, and real value. The difference? A system that works for you, not against you. It is time to rethink the PBM equation.
Let’s Dive In!
Let’s be real—you won’t get called out for picking the big-name PBM. The safe bet. The “steady hand.” But is that the whole story?
Nope.
Because playing it safe often comes with a cost. You’re stuck in a contract that looks good on paper but bleeds dollars in the real world. And here’s the kicker—you probably don’t even see it happening.
In the past, we’ve discussed Sunk Cost Fallacy and Switching Costs. These traps exist because you’re solving the wrong math.
The Right Math Problem No One Talks About
You measure activity: rebate dollars, discounts, contract terms that sound great. PBMs love that. They flood you with flashy reports, fancy charts, and savings that look good on paper. All math, right?
Wrong. That’s activity math. What you need is impact math.
Impact math asks:
Are these “savings” actually reducing total spend, or just shifting costs?
Does this ancillary program drive real value, or just add complexity and cause burnout?
What’s my net cost per script—after I factor in patient outcomes?
If you don’t have clear answers, your math is broken.
Consider Journavx, a classic example. Recently approved by the FDA, it comes in at $15 per fill. Some PBMs are balking. Too expensive, they say. Excluded from our formulary, they boast! But hold on—what math are they solving for?
A prudent PBM will say: Opioid dependence. Addiction. Return to work. Risk of overdose.
According to clinical trial data, Journavx eliminates all of those risks. So, what math are we solving for? A short-term cost on a spreadsheet, or the long-term human and financial cost of opioid addiction?
Bottom Line: Leaders who win aren’t the ones who play it safe. They’re the ones who run the right equation. They ask the right questions. They solve for impact, not just activity.
The Big 3 PBMs push their math because they know it solves their value equation—at your cost. The numbers don’t lie.
Let’s rewrite your value equation and build a pharmacy program that works for you. Trash the easy math. Do the right math —choose Prodigy.
Let’s chat.
Love at First Call: Prodigy’s Customer Obsession in Action
Valentine’s Day is just around the corner—a perfect time to celebrate love and appreciation. At Prodigy, we’re taking this moment to express our deep devotion to what we do: caring for patients and making your life easier. Your trust means everything to us, and we’re committed to delivering the kind of service that keeps the love alive—every call, every claim, every time.
Some PBMs play hard to get. Not Prodigy. We believe in answering every call, text, and email like it’s a love letter—within minutes, not hours or days. Our commitment to patient care is so strong, we put our service guarantees in writing—so you can hold us accountable. And while the average PBM’s Net Promoter Score (NPS) is heartbreakingly low, ours is 35 points higher than the industry average—but we’re not stopping there. We’re always striving to raise the bar even higher.
What are we solving for?
Nothing kills the mood faster than waiting—especially when it comes to critical medications. Patients shouldn’t be left in limbo and claims professionals shouldn’t have to chase down answers. Unfortunately, most PBMs leave clients feeling ghosted. At Prodigy, we take the opposite approach: immediate, accountable, and compassionate service that keeps everyone feeling valued.
How is Prodigy different?
We don’t play games. Every communication gets a response in minutes—because when patients are in pain, or claims need action, every second counts. And we back it up with performance guarantees.
Don’t just take our word for it—our clients are head over heels:
💖 “I needed my medication approved, and I expected the usual PBM delays. But Prodigy had it done in minutes. No hassle. Truly the best!” — Patient
💖 “I had an urgent claim, and Prodigy responded before I could even follow up. Prodigy is excellent at problem-solving, ensuring patients get their medications without delay. They don’t just promise great service—they deliver it.” — Claims Adjuster
💖 “Prodigy doesn’t make us chase them for answers. They’re always there, always responsive, always dependable.” — Claims Manager
💖 “Partnering with Prodigy helps us navigate the evolving challenges of pharmacy with ease. They provide our clients and claims teams with prompt, transparent, and reliable information.” — Executive
Love is about trust—and in the PBM world, trust is built on service —along with reliability, transparency, and accountability. Prodigy makes your life easier, your patients happier, and your claims process smoother. And unlike others, we don’t need sweet talk to prove it—our performance guarantees and industry-leading NPS speak for themselves.
This Valentine’s Day don’t settle for a PBM that ghosts you. Choose Prodigy—the only PBM that truly has a heart for service.
From All of Us at Prodigy
Happy Valentine’s Day ❤️
PBM Switching Costs: Why Staying Is Costing You Millions
Hey, there!
In my last email we tackled Sunk Cost Fallacy. A closely related concept is Switching Costs. This is particularly important when it comes to switching vendors, specifically PBM vendor.
Let’s cut to the chase: If you think switching PBMs is too expensive, you’re looking at the wrong price tag. The real cost isn’t in making the leap—it’s in staying locked into a system designed to drain your budget, limit your control, and put PBM profits ahead of patient outcomes.
Let’s Dive In!
You know the drill. The Big 3 PBMs (Caremark, Express Scripts, OptumRx) have spent years fine-tuning the art of the illusion of savings—hiding behind rebates, steering patients to their own pharmacies, and keeping pricing so opaque it would make a magician jealous.
And now, thanks to the FTC’s latest damning reports on Generic Markups and Vertically Integrated PBMs, we have the receipts:
$7.3 billion in overcharges on specialty generics—PBMs pocketing billions while payers foot the bill.
Markups of 1,000%+ on cancer drugs, all while PBMs pretend they’re “negotiating savings” for you.
68% of all specialty drugs flowing through PBM-owned pharmacies, ensuring they profit at every step.
A massive rebate shell game that keeps drug prices artificially high—and your costs soaring.
So let’s talk about the real cost of staying in this rigged system:
Every quarter you wait, you’re bleeding money into PBM profit margins.
Every renewal, you’re signing up for another year of opaque pricing and backdoor deals.
Every decision delay, you’re giving up control of your own pharmacy spend.
PBMs love to scare payers with “switching costs.” They warn of disruptions, complexity, and administrative headaches. But what they won’t tell you is that staying put means:
❌ Being locked into rebate schemes that drive up drug prices instead of lowering them.
❌ Watching your injured workers get funneled into PBM-owned pharmacies, where pricing is set to maximize their profit—not your savings.
Enough is enough. You need a PBM that works for you—not the other way around.
Where Do We Begin?
First Things First: Work with a PBM That Puts You Back in Control. As I’ve mentioned before, Prodigy is that PBM—move fast, think differently, and put patient outcomes ahead of profits.
Your next PBM partner must have these key qualities:
Transparent, pass-through pricing—no spread pricing, no rebate games, no surprises.
You own the data, you set the strategy—they execute your plans.
A focus on patient outcomes—not pharmacy steering, hidden fees, or billion-dollar markups.
While the Big 3 PBMs are defending themselves in court, PBMs like Prodigy are building smarter, more flexible pharmacy solutions that actually deliver results.
Bottom Line: Staying is the Real Risk. Switching is the Smart Play.
The Big 3 PBMs want you to believe switching is too hard, too expensive, too complicated. Why? Because they know that once payers see the truth, they leave.
The numbers don’t lie. The longer you wait, the more you lose.
Let’s rewrite the script. Let’s build a pharmacy program that actually works for you. It’s time to make the smart move. It’s time for Prodigy.
Ready? Let’s chat.
Sunk-Cost Fallacy
Hey, Its Del!
In my last email, we unpacked how fuzzy logic can cause leaders to justify keeping poor-performing partners—often at the expense of the team’s trust and patience. Judging by some of the responses, it seems some of you may have been battling another mental gymnastics move: the sunk-cost fallacy.
Think of it as loyalty to a bad decision just because you’ve already paid the price—whether it’s in time, money, or headaches. When it comes to PBMsand ancillary service providers, this fallacy can trap you into sticking with partners who overpromise, underdeliver, and never fail to invoice on time.
So how do you outsmart this cognitive trap?
Let’s Dive In!
The sunk cost fallacy is the tendency to stick with a failing strategy or partnership simply because of the resources or time already invested.This cognitive bias can have significant financial, operational, and clinical repercussions, particularly when decisions directly impact efficiency and outcomes.
For example:
Inefficient PBMs: Sticking with underperforming contracts can result in higher drug costs, poor patient outcomes, and limited transparency.
Outdated Ancillary Services Technology: Using outdated systems leads to operational inefficiencies, missed savings opportunities, and increased patient dissatisfaction.
Recognizing and addressing this bias is critical to improving performance, reducing costs, and optimizing patient care.
Where Do We Begin?
Here are a few savvy strategies to break free from the sunk cost trap and make sharper, more impactful decisions:
Think like a chess master: Stop making moves based on the board you wish you had. Evaluate your partners for their current performance, not past investments.
Use the “prodigy test”: If a brilliant, unbiased outsider reviewed your PBM and ancillary situation, what would they recommend? Hint: they’d probably suggest cutting your losses and calling Prodigy.
Make it a math problem: Focus on future returns, not sunk costs. If your current partner isn’t delivering value now, they’re unlikely to magically transform later.
Be a talent scout: Look for partners who are hungry, innovative, and aligned with your goals—prodigies who can outplay your current bench.
Recruit your team as your panel of judges: The rank and file often have a clear-eyed view of who’s delivering value and who’s just coasting. Lean on them for their expertise.
Hot tip! Test-Drive a Better Fit: Not ready for a full switch? Try before you buy. Pilot a new vendor on a small scale and let real results show you why change is worth it. If you’d like to test a PBM or ancillary solution before fully committing, try Prodigy.
The brilliance of breaking free from the sunk-cost fallacy is that it creates space for partners who will amplify your success rather than weigh you down. In other words: don’t be afraid to trade up.
Got a story about spotting—or escaping—this trap? Share it with me; I’d love to feature a real-world prodigy move in my next email.
Ready? Let’s chat.
The Trap of Fuzzy Logic
Hey, Its Del Again!
Let’s dive into another head-scratcher: how decisions—or indecisions—can sabotage your success and hit your bottom line. Ever find yourself clinging to a vendor that’s clearly dropping the ball? Maybe you’ve whispered, 'It’s not perfect, but switching feels like a hassle,' or, 'Better the devil you know, right?' Classic fuzzy logic trap!
It’s amazing how far a little fuzzy logic can go when it comes to justifying the unjustifiable—like sticking with vendors everyone knows are terrible. Decision-makers often ignore glaring pain points flagged by their teams, waving them off with excuses like, “It’s not perfect, but it works,” or “Switching would just be too much trouble.” Spoiler: it’s not working, and the trouble is already here.
Let’s Dive In!
Here’s the thing: ignoring the grumbles from the rank and file doesn’t make the problems go away. It just kicks the can down the road while costs quietly pile up—operational headaches, missed savings, and lost time you'll never get back. But instead of facing reality, fuzzy logic swoops in, convincing you that the devil you know is somehow safer than making a change.
Let’s get real—this is less about risk aversion and more about comfort with mediocrity. And mediocrity comes with a price tag. Every day you stick with a subpar vendor or partner, you’re leaving better results (and money) or personal growth on the table.
Where Do We Begin?
Enough talk—here are three smart ways to ditch the fuzzy logic and make sharper decisions:
1) Prioritize Numbers Over Nostalgia
Forget the warm fuzzies about "the devil you know." Look at the cold, hard facts. Missed deadlines? Rising costs? Let the data guide you, not your comfort zone.
2) Calculate the Cost of Inaction
Think staying put is easier? Think again. Add up the inefficiencies, missed savings, and wasted time. Spoiler: the real hassle is doing nothing while the costs pile up.
3) Test-Drive a Better Fit
Not ready for a full switch? Try before you buy. Pilot a new vendor on a small scale and let real results show you why change is worth it. If you’d like to test a PBM or ancillary solution before fully committing, Prodigy is here to help
Escaping fuzzy logic isn’t just about clarity—it’s about leveling up your game. If you have any doubts, give me five minutes to challenge your thinking about your current PBM or ancillary vendors. If you don’t walk away with valuable insights, I’ll buy you a coffee. But if I’m right, you’ll be one step closer to ditching the fuzzy logic and making a decision your whole team will thank you for.
Ready? Let’s chat.