Collaborative standards for PBM contracts in the CAA 2026 era.
How PBMs engage Nautilus to strengthen contract language, prepare for CAA 2026, and earn a place in the CAA 2026 Readiness 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.
Twenty-seven PBM standard contracts have been scored to date, and nine now publish their Fiduciary Alignment Score in the CAA 2026 Readiness Report. 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.
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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.
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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.
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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 Report. If not satisfied, the PBM is under no obligation to publish.
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4
Confidentiality preserved
The PBM retains all contract confidentiality protections under the NDA. No contract text is ever published. The report includes only the Fiduciary Alignment Score and tier designation.
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5
Withdrawal rights
The PBM may withdraw from future issues at any time. Participation in one issue does not bind the PBM to participate in subsequent issues.
04 · PBMs with CAA 2026 Ready contracts
Eleven contracts meet the standard.
A CAA 2026 Ready contract scores in the Excellent tier, 90 or higher, on the Fiduciary Alignment Score, and reaches Gold on the Data Sovereignty Index. Every PBM below reached it the same way: by rewriting its own standard contract language.
Nine were named in the inaugural CAA 2026 Readiness Report, published July 29, 2026. The rest qualified after publication. The next issue updates the list.
Inclusion reflects a PBM’s decision to open its standard contract to scoring, and the rating measures contract language rather than conduct, price, or service. No PBM paid to be scored, to be remediated, or to be listed. Recognition here is earned, and it can’t be bought.
Want your standard contract scored for the next issue?
The full market picture, 27 PBM standard contracts and 37 plan sponsor contracts scored against ten fiduciary provisions with a clause-level citation behind every judgment, is in the CAA 2026 Readiness Report. Foreword by Shawn Gremminger, President of the National Alliance of Healthcare Purchaser Coalitions.
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 report names only PBMs that agreed to disclosure. No other PBM is named in it. Aggregate market statistics draw on the full scored set with no company attached.
- Not a one-way evaluation. PBMs control whether their own score is published under their name. Nautilus does not attach a PBM’s name to a score 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 being scored for an upcoming issue of the Readiness Report is the right fit.