Collaborative standards for PBM contracts in the CAA 2026 era.
How PBMs engage Nautilus to strengthen contract language, prepare for CAA 2026, and participate in the National Alliance Quarterly Report on their own terms.
01 · The conversation plan sponsors are having
Plan sponsors are asking different questions than they did three years ago.
Audit rights, data ownership, rebate transparency, and administrative fee structure are no longer afterthoughts in renewal conversations. They are the conversation. Plan sponsors and the advisors who serve them want contract language that clearly supports the fiduciary obligations CAA 2026 codifies.
This shift is an opportunity, not a threat. PBMs that engage early help shape how the standards develop. They also have time to refine contract language thoughtfully, rather than in response to a renewal cycle or a regulatory deadline.
Nautilus exists to make that engagement productive for both sides.
The standards work best when the people drafting the contracts help shape them.
02 · How PBMs work with Nautilus
An independent standards body, working collaboratively with PBMs.
Nautilus Health Institute is a 501(c)(3) nonprofit. It is not a competitor to PBMs, not a consulting firm looking for engagement fees, and not a litigation-driven organization. Its role is to develop and maintain an independent framework for evaluating PBM contracts against fiduciary standards, and to apply that framework consistently and transparently.
The engagement model with PBMs is collaborative. The PBM brings the contract. Nautilus brings the framework. The output is a shared understanding of where the contract is strong, where it has gaps, and what specific language would close those gaps in the next renewal cycle or amendment.
Five to ten PBMs are expected to be participating publicly by mid-2026. Several are already engaged in the collaborative review process. The participating PBMs span a range of business models, from traditional spread-pricing relationships moving toward pass-through, to pass-through PBMs refining their language, to specialty and regional PBMs strengthening their fiduciary posture.
03 · What participation involves
A five-step process designed to protect the PBM at every stage.
Participation is voluntary, collaborative, and built around PBM control of the outcome. No part of the process publishes anything about a PBM without that PBM’s explicit consent.
-
1
Participation Agreement with NDA
The PBM and Nautilus sign a Participation Agreement that includes a non-disclosure agreement protecting contract language and confirming the PBM’s control over whether scores are made public.
-
2
Submission and collaborative review
The PBM submits the contract for Contract X-Ray analysis and participates in a collaborative review of contract terms, including recommended language changes to improve CAA 2026 readiness.
-
3
Opt-in publication
If satisfied with the process and the resulting score, the PBM agrees to publication of the Fiduciary Alignment Score in the CAA 2026 Readiness Quarterly Report. If not satisfied, the PBM is under no obligation to publish.
-
4
Confidentiality preserved
The PBM retains all contract confidentiality protections under the NDA. No contract text is ever published. The Quarterly Report includes only the Fiduciary Alignment Score and tier designation.
-
5
Withdrawal rights
The PBM may withdraw from future Quarterly Reports at any time. Participation in one issue does not bind the PBM to participate in subsequent issues.
04 · The CAA 2026 Readiness Quarterly Report
A public benchmark, published by the National Alliance.
The first CAA 2026 Readiness Quarterly Report publishes at RosettaFest 2026 in Nashville. The report contains two things: a list of PBMs that have agreed to publicly disclose their Fiduciary Alignment Score, and market statistics drawn from the Contract X-Ray reference set.
The list signals to plan sponsors and advisors which PBMs have stepped forward to demonstrate that their contracts support the fiduciary obligations CAA 2026 codifies. After RosettaFest, the report publishes quarterly. Participating PBMs may update their scores as contract language evolves.
First issue: July 29–31, 2026
What the Quarterly Report includes
The Quarterly Report is a transparency mechanism, not a certification or ranking. It identifies PBMs that have opted in to public disclosure of their Fiduciary Alignment Score. PBMs that do not participate are not named, scored, or referenced.
Target participation in the first issue is five to ten PBMs. The window to be part of the inaugural list is open through early summer.
05 · What this is not
A collaborative engagement, not an audit.
- Not an audit or enforcement action. Nautilus is an independent standards body. The engagement is collaborative, voluntary, and not associated with any regulatory enforcement.
- Not a public ranking. The Quarterly Report lists PBMs that opt in to disclosure. It does not name or evaluate PBMs that have not participated.
- Not a one-way evaluation. PBMs control whether scores are published. Nautilus does not publish PBM scores without consent under the Participation Agreement.
- Not a replacement for the PBM’s legal or strategy partners. The framework is one input to internal contract development. The PBM’s existing counsel and strategy teams remain in their roles throughout the engagement.
Start a conversation.
The first step is a 30-minute call to understand your contract, your timeline, and whether participation in the inaugural Quarterly Report is the right fit.