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The following issues make that risk worse when the wrong PBM model is in place: Specialty spend is concentrated in a small portion of the member population, making it hard to predict Most PBMs provide aggregate reporting that obscures where costs are actually coming from Without a contractual spend guarantee, employers have little protection against year-over-year increases Misaligned PBM incentives can quietly compound costs through steering, markups and rebate retention Impact on employee access and outcomes
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