Delivering on the PBM Mission
For all the attention pharmacy benefit managers receive these days, I still think there is a significant gap in understanding what PBMs actually do and how much complexity they manage every day. PBM’s not only manage affordable access to all types of medications, they set up the benefits, the pharmacy network, manage claims and eligibility, perform customer and provider services, manage pharma contracts, perform Utilization Management, assess clinical effectiveness of medications and more; all on behalf of the Plan Sponsor whether commercial or other coverage.
At its core, the mission is fairly simple: PBMs help people get timely, affordable access to the medications they need while helping plan sponsors provide benefits that support their Medicare/Medicaid patients or Commercial business employees and families. Delivering on that mission, however, requires PBMs to operate at the intersection of health plans, employers, pharmacies, providers, pharmaceutical manufacturers, wholesalers, regulators, and, most importantly, the patients who depend on them.
With patient health and safety, affordability and access as job number one, the pressure on the industry today feels different because so many parts of the business are changing at the same time.
Pricing models are moving toward greater transparency with rebate pass-through structures and cost-plus arrangements across pharmacies and PBM contracts. Federal and state requirements continue to evolve and change the way PBMs achieve margins to cover administrative costs. GLP-1s and a growing pipeline of high-cost specialty therapies will also challenge the economics of pharmacy benefits, requiring organizations to rethink coverage strategies. At the same time, many PBMs are still operating on fragmented technology and claims infrastructure that was not designed for the speed, complexity, or expectations of healthcare today.
We can’t remove all of that complexity from the healthcare system, but we can do a much better job of preventing patients, providers, and plan sponsors from having to navigate it themselves.
Price Is Becoming Table Stakes, but Experience Can Still Differentiate
Much of the conversation around PBMs today understandably focuses on cost and price transparency. Those issues matter, but I do not believe transparency alone will define the next generation of pharmacy benefits.
As the market becomes more transparent and pricing models begin to converge, experience becomes increasingly important. That includes the experience of the plan sponsor choosing and managing a PBM relationship, the provider trying to get a patient started and stay on therapy, and, most importantly, the patient trying to understand whether they can get the medication their doctor prescribed and what it is going to cost.
The challenge is that our industry has traditionally treated benefit configuration, pharmacy networks, specialty pharmacy, prior authorization, financial assistance, and fulfillment as separate processes. Patients do not experience them that way. To them, it is one experience that ultimately comes down to whether they can get the medication they need, whether they can afford it, and how quickly they can begin treatment.
When we look at the system from that perspective, every unnecessary handoff, delay, phone call, and disconnected system becomes an opportunity to improve the experience.
Specialty Pharmacy Makes the Problem Easy to See
Specialty pharmacy is one of the clearest examples of where this complexity becomes a very human problem.
A patient may be prescribed a specialty medication only to discover that the pharmacy does not have it available or cannot fill it. The patient may not even know there is a problem until days later. In the meantime, someone has to determine where the prescription can be filled, whether prior authorization is required, what the patient’s benefit covers, whether financial assistance is available, and what the patient’s out-of-pocket responsibility will be. The patient may also need a nurse to help coordinate infusion services or at home support.
Too often, the patient becomes the person connecting those dots. They call the pharmacy, their provider, and their health plan trying to figure out where their prescription is and what needs to happen next.
For someone managing cancer, an autoimmune condition, or another serious disease, those days matter. The administrative burden creates additional uncertainty at a time when the healthcare system should be making things easier for them.
This is where I see a very practical opportunity for AI.
When a prescription enters the system, intelligent agents could help determine benefit eligibility and authorization requirements, identify available inventory, evaluate pharmacy options and cost, determine whether the patient qualifies for patient or copay assistance, route the prescription appropriately, and coordinate communication with the provider and patient.
Instead of requiring the patient to navigate each part of the process, the technology can help coordinate the complexity behind the scenes and give the patient a much clearer path to therapy.
AI Can Help Us Rethink the Entire Workflow, Putting the Patient First
The opportunity for AI in PBMs is much bigger than making individual administrative tasks faster. The more interesting opportunity is connecting work that has historically been fragmented across systems, organizations, and teams.
Doing that well requires more than adding an AI tool to an existing process. AI systems need the context required to understand a member’s benefits, applicable policies and clinical criteria, network requirements, authorization status, pharmacy options, cost, and what has already happened in the process. They also need clear boundaries around what can be automated, what requires human judgment, and how every decision and action can be traced.
When that intelligence can move with the work, PBMs can begin designing processes around the outcome they are trying to achieve rather than around the systems and organizational structures that happen to exist today.
I believe the standard we should be working toward is extremely high accuracy combined with much faster execution wherever automation can be used safely. That could mean moving some processes that take days today to hours or even minutes while giving people better visibility into what is happening along the way.
Experience Will Help Define the Next Generation of PBMs
The reason this matters now is that the underlying technology is increasingly capable of supporting this kind of transformation, and expectations will change quickly once people experience a better way of working.
A patient who can quickly understand where a medication will be filled, what it will cost, and when it will arrive is going to have a very different experience from someone who spends days making phone calls. A prescriber who knows that authorization, affordability, and fulfillment are being coordinated can spend less time following up on administrative issues and more time caring for patients. A plan sponsor can begin evaluating its PBM not only on economics, but also on how effectively that PBM takes care of its employees and their families.
The organizations that lead will still need competitive pricing, strong networks, regulatory expertise, and disciplined benefit management. Those capabilities are not going away. What will change is the expectation that all of that complexity should be largely invisible to the people using the system.
PBMs do not just need to eliminate complexity. They need to help absorb it.
That means taking responsibility for connecting the systems, information, decisions, and actions that patients and providers are too often left to coordinate themselves. AI gives us an opportunity to do that at a scale and speed that simply were not possible before.
If we use it well, we can create a pharmacy experience where access happens faster, affordability is clearer, providers spend less time navigating administrative processes, and patients spend less time trying to understand how the system works and more time focusing on their health.
For me, that is the real opportunity in front of PBMs. The industry will remain complex, but the experience we create for the people depending on it does not have to be.
Further Reading:
CMS-0062-P: Drug Prior Authorization Moves Toward Faster, More Transparent Workflows
From Automation to Autonomy: Four Design Principles for Healthcare AI That Actually Work
About the Author
Michele Paige brings an operator’s perspective to one of healthcare’s most complex challenges: making prescription care more accessible, affordable, and easier to navigate. Having most recently led product and digital strategy at Elevance Health’s CarelonRx, she brings deep expertise in pharmacy benefit management, specialty pharmacy, and affordability initiatives. As an advisor to Autonomize AI, she helps shape how enterprise AI can simplify pharmacy operations and improve the experience for the people who depend on them.
