Contract X-Ray turns each term into a measurable standard.
Maybe We Should Call It Contract MRI
Contract X-Ray shines a light into contracts. But it works more like an MRI than a snapshot.
Each of the ten scored provisions is a thin slice, and each slice can be read alone or in combination to examine a different aspect of the contract in detail.
Fiduciary alignment is all ten slices at once. Transparency is five of them. Pass-through is two.
That’s how Contract X-Ray puts a precise, objective measure on terms the marketplace has distorted and vendor contracts have twisted.
For example, consider these definitions and how Contract X-Ray measures it:
Fiduciary Alignment
Definition: Fiduciary alignment is whether the contract supports the plan sponsor’s obligation to act in the best interest of participants and beneficiaries and to see that their costs are reasonable. A contract is aligned when the PBM’s conduct serves the plan, the plan’s money remains a plan asset, and the sponsor holds the control to verify and enforce both. It is misaligned wherever the PBM can put its own economics ahead of the plan’s. Transparency asks whether you can see the money. Alignment asks the harder question: across all ten provisions, does the contract hold the plan’s interests above the PBM’s
Contract X-Ray Measurement: All ten provisions, scored together. Each is scored from 0 to 100 against model contract language, across three domains: Fiduciary Conduct, whether the PBM acts in the plan’s interest; Financial Integrity, whether the plan’s money remains a plan asset; and Oversight and Control, whether the sponsor can see and enforce the deal. The ten are even weighted and average into one number, the Fiduciary Alignment Score.
Transparency
Definition: Transparency is whether the plan knows where every dollar is meant to go and can prove it. It has two halves the market routinely collapses into one. Disclosure means the vendor shows the plan every dollar paid and every dollar retained. Verification means the plan can check those figures itself, on data it owns, through an audit it controls. A number the plan can’t audit, on data it doesn’t own, is not transparent. Disclosure shows the numbers. Verification proves them. Transparency requires both.
Contract X-Ray Measurement: Five provisions. Disclosure is scored on pricing, rebates, and administrative fees. Verification is scored on data ownership and audit rights. All five should clear the Good threshold, 75 of 100. Fall below Good on any one and the contract is not transparent, because a partial right to verify is not a right to verify.
Pass-Through
Definition: Pass-through is whether money remains a plan asset or the PBM keeps a cut. In a pass-through contract, the plan pays the pharmacy’s actual price, receives every manufacturer dollar, and pays the PBM only the administrative fee the contract names. The PBM earns what it discloses, and nothing else. It is not pass-through if the PBM retains a spread on price, a share of rebates, or other manufacturer compensation.
Contract X-Ray Measurement: Two provisions. Pricing is scored on whether the plan pays the pharmacy’s actual cost with no retained spread or post-adjudication clawbacks. Rebates are scored on whether every manufacturer dollar reaches the plan, with none retained or defined away. Both must clear the Good threshold. Pass-through is necessary for transparency and for alignment, and sufficient for neither.
What the Heat Map Shows
We mapped 28 PBM contracts against the three terms
The three terms scored by PBM.
The result splits the market cleanly.
Seven PBM contracts clear all three terms. Their contracts meet the standard on transparency, pass-through, and alignment.
Every other one fails at least one. Some fail on transparency, showing numbers but blocking verification. Some fail on pass-through, they claim it but carve out exceptions. Some fail on alignment, individual provisions pass, but the structure still favors the PBM.
Seven clear the bar. The rest fall short on at least one term they claim to meet.
What to Do First Thing Monday
Request a Contract X-Ray. Your contract can be scored the same way every contract in this report was scored. Ten provisions. Three domains. One score. Email support@nautilushealth.org.
Talk with your Advisor. Share the results. Review the Negotiation report. Develop a plan to have your PBM remediate their contract.
Talk with your PBM. Recommend they submit their contract to Nautilus and start the process to become CAA 2026 Ready.
In Closing
For years, transparency, pass-through, and fiduciary alignment were words without definitions. Every PBM claimed them. No one could prove them.
Now they have definitions. Now they have scores. Now the question is whether your contract meets the standard.
Seven PBMs already do. The rest fall short on at least one term they claim to meet.
Every point between your contract and the best one has already been conceded by a PBM. The standard exists. The only question is whether you require it.
Once you see it, you can change it.
Here’s to clearer thinking, stronger plans, and better outcomes for the people who rely on us.
All the best,
P.S. Next week: You can know your number. The CAA 2026 Readiness Report is coming.
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