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PBM Innovations

Putting Patients at the Center

PBMs are not waiting for government interventions or unnecessary mandates to innovate and adapt to changing market conditions to help patients.

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The core mission of pharmacy benefit managers (PBMs) is to reduce drug costs for health plan sponsors and patients.

As drug companies continue to set and increase exorbitant prices for prescription drugs, PBMs are more valuable than ever to patients and payers. Consumers want access to the therapies and health care services that deliver on what Americans need to get and stay healthy, affordably, and conveniently. That’s why employers, unions, health insurers and other health plan sponsors hire PBMs to bring down costs.

As drug companies continue to increase prices annually, unprecedented demand for drugs is spurring an affordability challenge. The work to lower drug costs and increase affordable access requires the ability to constantly innovate and adapt to changing market conditions. PBMs are not waiting for government interventions or unnecessary mandates to address these market demands. Recently, PBMs across the industry, from big to small, have rolled out new, innovative programs to help plan sponsors tackle high drug costs, allowing patients to access the drugs they need.   

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Pharmacy Innovation Programs​

• Expanding reimbursement for clinical services so patients can receive more care at their local pharmacies.

• Using detailed data and other tools to help patients find savings, locate pharmacies, or receive critical social support.

• Understanding the unique needs of rural patients and supporting rural independent pharmacies through increased reimbursements and pharmacy networks.

• Offering employers and other plan sponsors the option of a pharmacy reimbursement payment model consisting of the acquisition cost of the drug, a set administration fee, and a pharmacy services fee.

Pharmacy Innovation Programs

PBMs recognize that pharmacies are an important part of patient care across the U.S.

Partnership programs between PBMs and pharmacies provide patients with a higher-quality, lower-cost pharmacy experience. Especially in rural areas, patients may depend on their pharmacist for more than filling prescriptions. PBMs across the industry are partnering with independent pharmacies so they can best serve their patient populations. 

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Access to GLP-1s for Weight Loss

Glucagon-like peptide 1 (GLP-1) agonists are a class of drugs that are indicated for improving blood sugar levels in type 2 diabetes mellitus, and three prominent GLP-1 drugs are also approved for chronic weight management.

According to one survey, in 2023, 91% of commercial plan sponsors covered GLP-1s for diabetes, while just 33% covered them for weight management. Employers often cite the increased costs of the weight management versions of these drugs as barriers to coverage. PBMs are responding to the evolving GLP-1 drug class to support employers and patients. 

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Access to GLP-1s for Weight Loss​

• Offering plan sponsors comprehensive programs that combine weight loss aids (such as GLP-1s) with lifestyle changes. These add-on programs consist of a behavior support component that helps patients make lifestyle changes related to obesity, through diet and exercise in conjunction with the use of GLP-1s.

• Encouraging the use of GLP-1 best practices to contain costs and promote access to patients in need.

• Recommending coverage and formulary placement of GLP-1s for weight management to employers and other plan sponsors when appropriate, allowing plan sponsors to design benefits that work for their unique populations.

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Patient Out-of-Pocket Cost Sharing Programs

• Limiting what is paid by patients to $0 or a low dollar amount for many common prescription drugs.

• Providing actionable information to patients, helping them understand and lower their out-of-pocket drug costs.

• Partnering with manufacturers to reduce patients’ costs at the pharmacy counter through coupons and other financial assistance programs.

• Offering prescription discount cards to lower the cost of drugs not covered by a patient’s plan.

Patient Out-of-Pocket Cost Sharing Programs

Even as the average cost-sharing payments for patients decline each year, two thirds of insured adults under 65 are worried about affording their prescription drugs. Many of these challenges with cost sharing result from exposure to high drug list prices set by drug companies. When high list prices affect affordability for insured patients, those impacted are less likely to get on and stay on their medication. 

PBMs offer employers, unions, and other health plan sponsors novel programs and ideas to help patients affordably access their prescriptions.

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Biosimilar Access

Biosimilars — biological drugs with no meaningful differences from FDA-approved reference biological products — offer patients opportunities for safe, effective, low-cost alternatives to expensive biologics.

PBMs are working with employers and other health plan sponsors to break down the barriers surrounding biosimilars and make them more accessible and affordable.

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Biosimilar Access

• Ensuring that patients have affordable access to biosimilars by recommending product placement, including removal of expensive reference biologics, on formularies to employers and other plan sponsors.

•Promoting the use of biosimilars by offering incentives to switch from higher-cost products to lower-cost ones or through low or $0 out-of-pocket cost sharing.

• Providing education to health care providers and patients on product safety through expert resources.

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Patient Transparency Tools

• Providing online web portals for PBM members to provide real-time and actionable information. Portals allow members to search for the lowest-cost prescription alternatives, find or compare prices across pharmacies, or access their prescription history.

• Increasing focus on streamlined transparency information through digital apps for patients. Many apps provide access to benefit ID cards to allow flexibility and convenience.


• Providing educational resources to patients helping them make more informed decisions. Information about pharmacy and provider cost and quality arms patients with important knowledge about their care choices.

• Supplying information to providers and pharmacists — including real-time benefits checks, lower-cost alternative recommendations, and prescription drug reviews — helps clinicians support their patients.

Patient Transparency Tools

Tools that provide transparency facilitate convenient access to information that empowers patients.

Educating patients leads to more informed choices and better savings opportunities. Technological innovations help patients access the right information at the right time, helping them live well:

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Clinical Adherence

Medication adherence – taking a prescribed medication appropriately – is vital to the health of patients, especially those with chronic diseases. Nonadherence is associated with poorer health outcomes and even increased mortality.

PBMs are working to support patients by using their technology and expertise to provide medication adherence programs that help patients take their drugs safely and appropriately. Market demand for more comprehensive services and stronger connections to patient health outcomes are prompting PBMs to expand their offerings accordingly. The clinicians, pharmacists, and advisors working for PBMs use advanced technology and analytics to identify the patients in need and provide the tools and support to help.

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Clinical Adherence

  • Establishing medication therapy management (MTM) programs, which target patients who are on multiple medications that benefit from improving the use of medications through personalized recommendations and support. 
  • Offering patient assistance programs to help remove cost barriers for patients, helping them afford their medications and reducing prescription abandonment rates.
  • Recommending 90-day supply and automatic refill programs through retail and mail order to increase adherence, as patients who receive 90-day supplies have higher adherence rates compared to 30-day supplies. 
  • Providing individuals with specific chronic conditions personalized support including medication reviews, routine one-on-one discussions, and actionable recommendations to improve medication adherence and close gaps in care.
  • Providing data, educational materials, and support to providers, pharmacists, and plan sponsors to help monitor abandonment rates – due to factors like cost, side effects, or drug shortages – that decreases access to medications.