The Nautilus PBM Procurement,
Contracting & Management Project

The Nautilus PBM Procurement, Contracting and Management Project

We scored 27 PBM contracts against the same ten provisions. The median was 54.

Middlemen are all over healthcare. They stand between you and your doctor. Your hospital. Your pharmacy. Taking a cut at every step, and the contracts make it legal.

Nautilus publishes what employers and advisors need to act on that: open-source procurement tools, contract standards, and independent contract scoring.

Dot plot of Fiduciary Alignment Scores for 27 PBM standard contracts on a 0 to 100 scale. Ten score Red Flag below 45, six score Concern, one Fair, one Good, and nine Excellent at 90 or above. The median is 54.

CAA 2026 Readiness Report, inaugural issue, July 2026

Inaugural issue · 19 pages

Published July 29, 2026 · Inaugural issue

Most PBM contracts fall short of 60, even at their best. Nine clear 90.

For the first time, the difference is measured, not argued.

Nine PBMs opened their standard contracts to independent scoring. All nine now rate Excellent, and not one of them started there. Two began in Red Flag, four in Concern, three in Fair. Each rewrote its contract to reach the standard, gaining 39 points on average. Six went through four or more rounds.

The rest of the market has not moved. How a PBM makes its money predicts almost everything: transparent pass-through contracts average 92, spread-priced contracts average 32. Of the 37 plan sponsor contracts scored, not one reaches Good.

27PBM standard contracts scored

54Median Fiduciary Alignment Score

9Rated Excellent, the first CAA 2026 Ready cohort

0 of 37Plan sponsor contracts that reach Good

Download the report Score your own contract with Contract X-Ray

New from the Nautilus PBM Project

Do you know what your PBM contract actually says?

Contract X-Ray reads a PBM contract and scores it against ten fiduciary-aligned provisions. You get a Fiduciary Alignment Score from 0 to 100, a tier for every provision, and the specific language that needs to change. Independent, standards-based, and built for the people who have to defend the decision.

Quick Look

Free

A first read on all ten provisions, delivered by email. Enough to tell you whether the contract deserves a closer look.

Full Assessment

Premium

Contract Scorecard, Negotiation Report, Executive Brief, and Data Sovereignty Score. Issue-level findings with the language to ask for.

CAA 2026 Readiness

Standard

Where the contract stands against the disclosure requirements taking effect in 2026, provision by provision.

Analyze your contract

Contract X-Ray is built and operated by Nautilus Health Institute, a 501(c)(3) nonprofit. It scores contracts, not companies. Every score reflects what a specific contract says.

From Why to How — and All the Way to Done

The PBM system is broken. You can fix yours. We’ll show you how.

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PROJECT OVERVIEW

The Nautilus PBM project offers not just insight —
but implementation guidance and resources.

Designed by Experts.
Built for Employers & Advisors.

Contract Smarter. Procure Better. Pay Less.

These tools are built for advisors, employers, and fiduciaries who are done settling.

CORE TOOLS

PBM Field Guide
Evaluation Questions
Model Contract Language
Data Specification
RFI / RFP Configurator

EXECUTIVE RESOURCES

Executive FAQ
Mark Cuban Advice To CEOs
Biggest Risks in Rx Benefits
What Employers Should Know

REFERENCE MATERIAL

PBM Company List & Profiles
Case Studies
Curated Industry Content
PBM Glossary

DOWNLOAD ALL OTHER RESOURCES

ACCESS THE PBM CONFIGURATOR

Advisors. Employers. Advocates. All In.

If you’re ready to challenge the status quo in pharmacy benefits, you’re in the right place.

ADVISORS

Elevate your impact. Simplify your process.

Strengthen your value proposition to employer clients
Reduce the time, cost, and complexity of PBM RFPs
Benchmark PBMs and pricing models with confidence
Ask smarter questions, get stronger answers
Stay current with best practices, pitfalls, and contract traps
Gain expert insight to guide fiduciary decisions

EMPLOYERS

Lower costs. Less risk. Better oversight.

Cut through complexity with clear procurement tools
Know your PBM options and what really drives value
Benchmark vendors, prices, and practices — fast
Strengthen your negotiating position with facts
Use validated tools to support board-level oversight
Derisk transitions and document fiduciary compliance

ADVOCATES

Turn concern into outcomes.

Access research, case studies, and educational tools
Share employer-ready materials with your networks
Support adoption of fiduciary-aligned PBM models
Help amplify change through stories, data, and policy
Collaborate on campaigns, legislation, or reform efforts
Contribute insights and shape real-world solutions

DOWNLOAD RESOURCES

Written for the people who sign the deals

Once you see it, you can change it.

The leadership book executives are handing to their boards.

The Middleman's Cut pairs Mark Cuban's plain-spoken case against healthcare's middlemen with a fiduciary playbook a board can act on. It speaks to the people who set priorities and sign the deals.

It reads like a leadership book, because it is one. The duty is real, the fix is practical, and the questions inside make the conversation easy to start.

Fewer than 1 in 8 contracts we have scored meet the top fiduciary standard.

Get your copy on Amazon See where your contract stands

All author proceeds benefit Nautilus Health Institute, a 501(c)(3) nonprofit, and fund the mission. This book draws on Mark Cuban's public comments, used with his permission. He did not write, co-author, or review it.