The DBI Index
Measuring the pharmacy benefits industry's alignment with Drug Benefit Integrity standards.
March 2026 Assessment
4/100
Industry DBI Score
The pharmacy benefits industry meets virtually none of the five structural requirements for independent drug benefit integrity. This is not an indictment - it is a baseline.
Scoring Matrix
| Requirement | Traditional Vertically-Integrated CVS/Caremark, Express Scripts, OptumRx | Transparent / Pass-Through Capital Rx, RxBenefits, SmithRx | Health Plan-Owned Elevance/IngenioRx, Centene | GPO-Backed Ascent, EmsanaRx | Independent Verification |
|---|---|---|---|---|---|
| Real-time all-channel routing | ✕Not Met | –Partially Met | ✕Not Met | –Partially Met | ✓Met |
| Licensed pharmacy, no channel ownership | ✕Not Met | –Partially Met | ✕Not Met | –Partially Met | ✓Met |
| Manufacturer-direct in benefit | ✕Not Met | ✕Not Met | ✕Not Met | ✕Not Met | ✓Met |
| Independent pharmacy fulfillment | ✕Not Met | –Partially Met | ✕Not Met | –Partially Met | ✓Met |
| Decision-level records | ✕Not Met | ✕Not Met | ✕Not Met | ✕Not Met | ✓Met |
Traditional Vertically-Integrated
CVS/Caremark, Express Scripts, OptumRx
Transparent / Pass-Through
Capital Rx, RxBenefits, SmithRx
Health Plan-Owned
Elevance/IngenioRx, Centene
GPO-Backed
Ascent, EmsanaRx
Independent Verification
Assessment by Model Type
Traditional Vertically-Integrated - CVS/Caremark, Express Scripts, OptumRx
In vertically integrated models, the entity managing the benefit also owns dispensing channels - specialty, mail-order, and retail. Routing decisions and fulfillment share common ownership, creating structural overlap.
Transparent / Pass-Through - Capital Rx, RxBenefits, SmithRx
Pass-through PBMs have made significant progress in eliminating spread pricing and improving reporting transparency. However, most do not hold pharmacy licenses, do not evaluate manufacturer-direct channels, and assess their own network decisions internally.
Health Plan-Owned - Elevance/IngenioRx, Centene
The health plan's relationship with its PBM and affiliated pharmacy operations creates structural overlap similar to vertically integrated models.
GPO-Backed - Ascent, EmsanaRx
Group purchasing models improve pricing leverage but typically do not operate as licensed pharmacies, do not evaluate manufacturer-direct options, and lack decision-level documentation.
Independent Verification -
Licensed pharmacy with no channel ownership, real-time routing across all channels including manufacturer-direct, fulfilled through independent pharmacies, with automatic decision-level records.
Methodology
The DBI Index evaluates structural conditions, not individual company performance. Each requirement is assessed against publicly available evidence - SEC filings, FTC enforcement actions, CMS data, published contract structures, and corporate disclosures. Ratings are: Met (structural conditions fully exist), Partially Met (some elements present but structural gaps remain), Not Met (structural conditions do not exist). The Index is updated monthly.