Don’t Be Fooled by CVS’s New “Guaranteed Net Cost” PBM Business Model


The pharmacy benefit manager (PBM) CVS Caremark has offered its self-insured corporate clients an alternative business model called “Guaranteed Net Cost”.  The pricing scheme features 100% pass-through of drug rebates and the end of rebate retention as an opaque source of PBM gross profits.

But, CVS has glossed over the fact that their “guaranteed net cost” price to plans is not the same as the net costs to them.  Until CVS tells us otherwise, the new business model allows for a opaque markup on top of PBM net cost. In graphs below, we demonstrate how a markup of guaranteed net costs serves as an opaque offset to foregone rebate retention.  

It is naive to think that CVS Caremark is about to give back a significant source of its annual gross profits without some sort of offset. In fact, CVS admits as much as their spokesperson is quoted as saying

CVS’ manager of corporate communications, Christina Beckerman, told Fierce Healthcare that the company does not expect CVS Health’s profitability to increase or decrease as a result of the shift to 100 percent pass-through rebates.

It is not even clear that CVS’s new business model lessens the incentives to Pharma to inflate list prices in order to compete on rebates for formulary placement.

The Problem With the Current PBM Business Model

The current PBM reseller business model features five major streams of revenue and gross profits.  Four of the five are opaque.

  1. Opaque rebate retention % on speciality (biotech) drugs in return for preferred or exclusive placement on formularies;
  2. Opaque rebate retention % on small molecule brand drugs in return for preferred or exclusive status on formularies;
  3. Opaque profit margins on 90-day generic Rx filled by captive mail order operations of the PBM;
  4. Opaque “spread margins” added by the PBM on top of reimbursements to retail pharmacies included in their networks;
  5. Transparent claims processing and data fees.

The opacity of drug rebates is magnified by the fact that reimbursements for brand drug Rx and related rebates come at different times.   It is impossible for plans match up these two streams and calculate a single net price its pays per drug.

Since the early 2000s, PBMs have continually come under attack for not acting in the best interest of their clients.  We have written a number of papers since 2004 pinpointing an opaque reseller business model as the source of this misalignment.

The PBM reseller business model is in stark contrast to two other transparent business models used by managed care companies:  

  1. a PMPY fee-for-service agency model where 100% of all reimbursements and rebates are passed through to plans.
  2. a risk-based insurance model with capitated premiums paid by plans.

Until the PBM Medco’s merger with Express Scripts in 2012, Medco’s financial 10-Q and 10-K reports to the SEC broke out gross rebates received — a credit to cost of sale — and rebates retained — a credit to sales.  We were able to calculate with certainty Medco’s “rebate retention rate”, a name we coined fifteen year ago in 2003.

We calculated that Medco’s rebate retention rate — the percentage of gross rebates retained — fell from 55% in 1Q03 to 28% in 2Q05.  This rapid decline was due to the sudden awareness by clients of the whole rebate retention scheme. To offset this loss, Medco began to push clients toward its captive mail order and fat margins it began to earn on mail order generic Rx fills.

The share of Medco’s overall gross profits coming from retained rebates reflected  outrageous rebate retention rates.  For 3Q04, we derived with certainty from Medco’s 10-Q that 71% of its gross profits came from retained rebates from small molecule brand drugs.  By 2Q05, we estimated with certainty that Medco’s retained rebate share of gross profits had dropped to 48% with the difference going to their newly found focus on mail order generics.

In our 2017 paper “Three Phases of the PBM Business Model”, we carried forward our mid-2000s work on disaggregating PBM gross profits by sources.  Below is a summary of that work.

Here is a graph of the above data:

CVS’s Guaranteed Net Cost Business Model

On December 5, 2018,  CVS Caremark introduced a new pharmacy benefit manager (PBM) business model option for self-insured corporate drug benefit plans.   

The core of this new business model is a simplified reimbursement price paid by plans to CVS that the company craftily describes as “Guaranteed Net Cost”.  Craftily, in that this so-called “cost” is really a “price” where the difference between “cost” and “price” is a markup.

The company touts the following distinguishing features of this simplified reimbursement price.

  • Drug cost predictability and simplicity
  • 100% of rebates are passed through to plan sponsors
  • Simpler payments flow — no retrospective rebates or inflation adjustments
  • Simpler way to compare different PBM contract proposals

Note this new pricing model is for brand drugs only dispensed at retail, mail order and specialty pharmacies.  The generic Rx drug reimbursement pricing scheme remains the same. That is to say, it preserves an opaque “spread margins” that PBMs like CVS add on top of CVS reimbursements to retail pharmacies for generic Rx drug fills.

This new CVS’s initiative clearly is in response to the tsunami of criticism by plan sponsors over an opaque PBM business model and the difficulty in matching initial Rx reimbursements at an inflated list prices with retrospective rebates occurring months later.

The Problem with CVS’s Guaranteed Net Cost Business Model

One: Opaque Markups

The problem with CVS’s new business model is that guaranteed net cost to plans is not necessarily the same as the net cost to PBMs. CVS never states unequivocally that its guaranteed net cost to plans = net cost to CVS.  In other words, CVS’s new business model allows for an opaque markup on top of its net cost.

Consider this meta:  CVS opaquely is substituting one opaque source of gross profits — guaranteed net cost markup — for another opaque source — retained rebates.

It is naive to think that CVS is about to give back some of its oligopolistic profits.  In fact, CVS admits as much as their spokesperson is quoted as saying

“ CVS’ manager of corporate communications, Christina Beckerman, told Fierce Healthcare that the company does not expect CVS Health’s profitability to increase or decrease as a result of the shift to 100 percent pass-through rebates”

The following is a numeral example of how the opaque markup can serve as a 1-for-1 substitute for retained rebates:

Here is a graphical depiction of our view that CVS is substituting an opaque markup for an opaque rebate retention:

To CVS’s credit, its new guaranteed net cost eliminates timing complexity. It does this by taking a risk and netting the current period Rx reimbursement with an estimated “expected” rebate rather than wait to credit plans with the actual rebate when it is paid by Pharma months later.  

CVS certainly is justified in including some markup as compensation for taking the risk that their estimated expected rebates turn out to be less than actual rebates.

Instead, CVS decided not mention markup at all,  let alone a justified markup as a compensation for assuming timing risk.

TWO: Doubtful Elimination of Incentive to Play the High List – High Rebate Game

Under the current retained rebate business model,  PBMs are incentivized to favor drugs with the highest gross rebates to the exclusion of therapeutically equivalent drugs with the lowest net cost.  To be in a position to win this rebate game, Pharma is driven by the PBM-created rebate game to inflate list prices for its brand drugs.  See our paper: Blame PBMs (Not Pharma) for Drive Drug Price Inflation.

The list price – net price bubble began around 2010 and reached its peak in 2017. It was in 2017 that AbbVie first broke the PBM rebate game  winning formulary placement by Express Scripts despite pricing its late entrant Hepatitis C Virus (HCV) drug Mavyret with an ultra low list price with no rebate potential.  However, this was an exception and the norm remains that the basis for formulary placement is gross rebates over net price (list price – gross rebates).

Below is a graphical depiction of how AbbVie broke the rebate game with its ultra low list = no rebate drug HCV drug Mavyret.

It is possible that the rebate game of high list – high gross rebate may be lessened under CVS’s new guaranteed net cost new business model. This is because the basis for PBM profits — markups — could be any number as opposed to being tethered to something like % of gross rebates or % of net cost.

Below is a depiction of CVS’s flexibility in choosing a markup that is independent of the list price or gross rebate. 

On the other hand, we can see the possibility that the new business model preserves the status quo. Here is our line of reasoning for this:

it is likely that brand drug list prices, which are publically available,  will serve as an upward bound for guaranteed net cost as it would look bad for CVS to set a guaranteed net cost that exceeded a drug’s list price.

To look good, CVS will want to show that guaranteed net costs is consistently 40% to 70% below the brand list prices.  

To achieve these percentages while still having room for oligopolistic markups, CVS will signal to Pharma that, while formulary placement is no longer based on gross rebates, high list – high rebate drugs afford CVS latitude in setting guaranteed net cost markups.

Below is a graphical depiction of why, under the new business model, CVS still would be incentivized to favor the high list – high rebate drug.

Iron Throne: Kingdom — Another Failed Game Release By Netmarble


Netmarble’s newly released game Iron Throne: Kingdom is a failure based on App Annie data.

While the stock did fall to a low of 123,000 KRW in August 2017, it has since recovered since April 2018 due to a timely 25%  investment in a Korean music label that is home to the K-Pop sensation BTS.

Once the failure of this new game become evident to investors, we believe that the stock will again test its all time low of 123,000 KRW.


Our analysis of Netmarble’s April 2017 IPO was that it was “priced for perfection”.  While the Lineage 2 game releases have been near perfect in Korea and Japan, its release in the USA has been a bust and the release in China is on hold due to geopolitical tensions.

As a result, we predicted that Netmarble’s stock would fall 45% from its November 26, 2017 closing price of 188,500 KRW to around 103,378 KRW once the revenue impacts of the USA and China releases were fully understood by investors.

While the stock did fall to a low of 123,000 KRW in August 2017, it has since recovered since April 2018 due to a timely 25%  investment in a Korean music label that is home to the K-Pop sensation BTS


Recently, Netmarble announced a May 2018 world-wide release of another MMO game called Iron Throne: Kingdom.

Based on App Annie data, we can already tell that the game is a bust with a global annualized revenue run rate (ARR)  that will never be more that $50 Million USD.  This is a drop in the bucket for Netmarble whose 2017 revenue in the range of $2,000 Million USD.

Here are the current revenue ranks on iOS Apple Store for the Iron Throne: Kingdom:

  • USA — #177
  • Japan – #363
  • South Korea — #29

The relation between revenue and revenue rank for mobile games is a power function which we have discussed in other papers.  A top 3 revenue rank game generally translates into a ARR of $1+ Billion which was the case for Lineage II.  A top 10 game drops down severely to $ 160 ARR.



Here are the App Annie revenue rank charts for the game on iOS Apple for the USA, Japan, and South Korea.

iOS USA — revenue rank 177 on June 4, 2018

iOS Japan – revenue rank 262 on June 4, 2018

Roblox Corporation: A Slow Climb To the Top of the App Store Charts

Two days after Christmas Day 2017,  we checked out App Annie to see which paid and which free-to-play mobile game (f2p) with in-app purchases (IAP) spiked into Top 10 revenue rank.

You see Christmas Day is #1 day of the year for paid mobile game purchases and IAP for f2p games.

This is because pre-teens, teens, heck everyone, receives  app store gift cards from Gramps and Grandma.   Gamers use the gift cards THAT DAY to make game purchases from the app stores.  Not just spur of the moment purchases.  But, “wish list” purchases they had been thinking about for the past several months knowing full well they would be receiving app store gift cards for Christmas.

Our thesis is that game that spikes in revenue rank to the Top 10 on Christmas is the best game of the year.

We have been using App Annie to value mobile game startups since 2013.  Just after Christmas 2014, we noticed that the paid game “Five Nights at Freddy’s” by indie developer Scott Cawthon spiked to #10 on Christmas Day.  

We thought nothing of it at the time.  Later, in April 2015, we published an article on the game called Life Lessons From Five Nights at Freddy’s.  In November 2015, we answered the following question posed  by a mobile game developer on Quora:  What’s the best time to release an iOS game to get maximum downloads?  Our answer on Quora was:

In terms of paid games, the absolute best time to launch is before Christmas day.  This is because many kids receive Apple iTunes gift cards for Christmas and spend Christmas day downloading all the paid games on their “wish list”.

Last Christmas Day December 25, 2014 belonged to Scott Cawthon’s Five Nights at Freddy’s  where the  $2.99 paid game shot up to #10 revenue rank on iOS Apple USA according to App Annie analytics.   

Between 2015 and 2017, we did not look for Christmas favorites on the App Store. We were too focused on exposing the bad guys of mobile gaming rather than the good guys:

Kabam and their “talk the talk” culture that lead to their downfall

Kabam: $800 Million Bid Is Both Lifeline And Death Knell

Kabam: A Mobile Game Unicorn No More?

A Unicorn Startup’s Kiss of Death: Kabam Field

And the Korean company, Netmarble, who bought Kabam’s Vancouver studio and then proceeded to wreck two game communities with Patch 12.0 for Marvel: Contest of Champion and Patch 6.3 for Marvel: Future Fight

Netmarble IPO: Priced for Perfection

Netmarble IPO: How Greed Destroyed Its Kabam Acquisition

Netmarble’s Marvel Future Fight: The Boycott is Now Measurable

But, just when we couldn’t get any more depressed about mobile game companies as we witnessed Netmarble’s destruction of the Marvel:Future Fight community,  we just happened to check out the App Annie charts for Christmas.

Low and behold, who did we discover spiking to #3 on Christmas day and #2 on the next day  but


Note: the spikes in revenue rank coincide with Fridays – Sundays.  Unlike “grinder” or “play or be destroyed” mobile games, you can put Roblox down during the week, then go back to it on the weekend without any loss in game assets.

And, we expanded the App Annie chart to discover that Roblex had been building a stronger and stronger community FOR YEARS.


We are so happy for Roblox.  Spiking to #2 on App Annie charts the day after Christmas 2017 is a sign to us that Roblox is the mobile game and company of the year.

Roblox has integrity.  No crass monetization like Netmarble’s  random number generator (RNG)  lockboxes introduced in their Patch 6.3 of Marvel: Future Fight.   No radical nerfing of Champions like what Kabam and Netmarble did with Patch 12.0 for Marvel: Contest of Champions

We are not going to spend much space talking about Roblox the game or Roblox the company.  You can read it here on their website

You should also check out this YouTube video of CEO and founder David Baszucki giving a tour of their studio in downtown San Mateo, California.  Also check out this YouTube video narrated by Baszucki on the company’s beginning.   Totally warped sense of humor that we like.

Speaking of YouTube,  we wonder if the folks at Roblox know that their studio is located right across the street from the 2005 original office of YouTube.       (BTW, San Mateo is happening for startups) 

Roblox  2017 : 69 E. 3rd Street San Mateo, CA


YouTube 2005: 60 E. 3rd Street, San Mateo CA.


Marvel Future Fight Game: The Boycott is Now Measurable

“The revolution will not be televised” per Gil Scott-Heron, but the boycott is now measurable

Keep up the boycott until Netmarble rolls back Patch 3.6

App Annie revenue rank chart as of December 27th – now down from  #38 on 11-29-17 to #127 on 1-5-18  KEEP IT UP

These are the two responsible for Patch 3.6

CEO of Netmarble Games Corp. Bang Joon-hyuk



GM of Netmarble U.S. Shim Chul-Min

Netmarble’s Game a Bust in the USA – Stock Price Target- 103,000 KRW


Our analysis of Netmarble’s IPO was that it was “priced for perfection”.  While the Lineage 2 game releases has been near perfect in Korea and Japan, its release in the USA has been a bust and the release in China is on hold due to geopolitical tensions.

As a result, we predict that Netmarble’s stock will fall 45% from its November 26, 2017 closing price of 188,500 KRW to around 103,378 KRW once the revenue impacts of the USA and China releases are fully understood by investors.

Netmarble’s IPO Valuation: Priced for Perfection

On May 11, 2017, Netmarble Games had an IPO on the Korea KOSPI stock exchange.

Due to an enthusiastic demand by Korean, International, and Sovereign funds, the company was able to price the IPO at the high end range of 157,000 Korean won (KRW) per share, or approximately $138 USD per share based on an exchange rate of .00088 KRW / USD.

Three days before trading began,  analyst Moon Ji-hyun with the Korean brokerage house of Mirae Asset Daewoo predicted that the company would exceed expectations for YoY revenue and profit doubling.  She gave the stock a price target of 200,000 KRW, or a 27% increase from the IPO price.  

Most other financial analysts and business reporters wrote positively about the company and its IPO.

Within the first hour of trading, individual retail investors pushed the price up to 171,500 KRW. The stock closed the day at 162,000 KRW, making the funds, the underwriters, the company and its CEO Bang Jun-hyuk very happy.

We alone differed.  (Disclosure: we have never held a position in the stock and do not intend to initiate one at anytime.  We have not received any remuneration for our articles on Netmarble.)

Three weeks before the IPO, on April 18, 2017 we analysed the offering and estimated that Netmarble’s post-IPO forward price sales ratio would be 4.3.  This was based on FY17 YoY reported sales forecasts of a revenue doubling — largely driven by its newly released game Lineage 2: Revolution.

We found that Netmarble’s post-IPO valuation exceedingly high by both South Korean and Western standards for mobile game companies.  

For example, we calculated the current price sales ratio of the very successful Korean mobile game company Com2uS at only 2.6.  We also calculated the market-derived current price sales ratio of King Digital at only 3.08 based on what Activision Blizzard paid to acquire King in 2015.

Netmarble’s 2017 Performance

Our assessment in April 2017 was that Netmarble’s IPO was “priced for perfection” based on a forward price sales ratio of 4.3.  We wrote another paper in May 2017 predicting that the stock would fall 33% from the IPO price to around 105,000 KRW once investors realized that Netmarble’s 2017 sales would fall short of expectations.

To Netmarble’s credit, its performance has been near perfect in the Korean and Japanese releases of Lineage 2.  After a couple of months of drifting downward,  the stock has recovered 47.8% from a low of 127,500 on August 11, 2017, largely due to the strong Japanese release.

On November 15, 2017, Netmarble released Lineage 2 in United States. Our assessment is that the release is a bust as games destined to be long-lasting hits in the USA usually crack the Top 10 iOS revenue rank on the App Annie charts within weeks of release.  The game has now sits at revenue rank #30 which we estimate translates to an annualized run rate in the neighborhood of $75 Million.

Below is the App Annie USA iOS revenue rank chart for Lineage 2:

The stock market has yet to factor in Lineage 2’s bust in the USA.

Also, the 2017 scheduled release of the game in China has been delayed due to geopolitical tensions between the two countries.

Below is a summary of Netmarble’s game performance in 2017 to date:

While Netmarble’s 4th quarter revenue figures should be at an all time high due to the successes of Lineage 2 in Korea and Japan, we forecast that Netmarble will miss analysts’ full year sales estimate of $2.3 Billion (2.5 Trillion KRW), or a revenue doubling,  by 14.8%.

We do not believe that the revenue impacts of the failed USA release and delayed China release are fully understood by investors.  The realization that Netmarble will fail to meet full FY17 revenue doubling forecasts should cause a compression in Netmarble’s IPO valuation multiple of 4.3 times sales.   

Assuming a more realistic multiple of 3.5, we predict that Netmarble’s stock will fall 45% from its November 26, 2017 closing price of 188,500 KRW to around 103,378 KRW within the next three months.