Pharmacy Benefit Managers (PBMs) are navigating one of the most complex moments in healthcare. Mounting pressure from rising drug costs, evolving regulations, and growing member expectations is forcing PBMs to rethink how they operate. Manual processes—especially in prior authorization, benefit verification, and medication adherence—slow down therapy starts, drive up administrative costs, and erode satisfaction for providers and members alike.
Emerging AI and automation technologies are helping PBMs modernize these workflows, creating faster, more transparent, and more personalized engagement across the pharmacy ecosystem. By digitizing routine interactions and enabling secure, data-driven decision-making, PBMs can focus resources on what matters most: improving access to medication, adherence outcomes, and member experience.
(Source: Ushur for PBMs 2025; AI & Automation for PBMs Guide)
TL;DR – The Short Answer
Pharmacy Benefit Managers (PBMs) are under pressure to cut costs, improve adherence, and prove value to payers. Ushur’s AI-powered Customer Experience Automation™ (CXA) platform helps PBMs automate high-cost manual workflows — like prior authorization, benefit verification, and medication adherence programs — to accelerate therapy starts, lower call center volume, and deliver measurable outcomes in a fully HIPAA- and HITRUST R2-compliant way.
What Is a Pharmacy Benefit Manager (PBM) and Why Are They Turning to AI?
PBMs sit at the center of today’s healthcare ecosystem, balancing costs, access, and outcomes. Yet manual processes and fragmented communication make that role harder every year.
Key challenges include:
- Medication non-adherence: 50% of Americans don’t take prescriptions as directed, costing $500B annually.
- Therapy delays: Manual prior authorizations and provider friction can cost PBMs up to $8M per day in delays.
- Rising call center costs: Each call center FTE costs $33K–55K per year — much of it spent on repetitive tasks.
- Competitive pressure: Health plans and employers demand measurable outcomes and digital-first experiences.
How Can AI Help PBMs Automate Prior Authorization?
Quick Answer:
AI-powered automation replaces manual workflows with secure, rules-driven, and context-aware digital processes that cut prior authorization time from days to minutes — while maintaining full HIPAA compliance.
Ushur’s Customer Experience Automation (CXA) platform automatically gathers information, validates data, and updates systems — reducing turnaround time from days to minutes.
Benefits:
- Fewer fax, phone, and email dependencies
- Real-time status updates to members and providers
- Faster time-to-therapy and reduced staff burden
- Proven compliance with HIPAA, HITRUST, TCPA, and ADA/WCAG standards
How Does AI Improve Medication Adherence for PBMs?
Quick Answer:
AI automation supports medication adherence by proactively engaging members through personalized digital channels to encourage on-time refills and surface barriers like cost or side effects.
Medication adherence directly impacts PBM rebate revenue and patient outcomes. Ushur’s AI automation engages members proactively — via text, email, or the Invisible App™ — to encourage on-time refills and identify barriers to adherence such as cost, side effects, or transportation.
AI-driven workflows include:
- Personalized refill reminders and education
- Adaptive questionnaires to uncover adherence challenges
- Two-way messaging with care teams or pharmacies
- Integration with PBM systems to trigger follow-ups and reporting
What AI Use Cases Deliver the Fastest ROI for PBMs?
Quick Answer:
The fastest ROI comes from automating workflows with high manual volume and measurable outcomes: prior authorizations, benefit verification, and adherence programs.
How Is Ushur’s AI Different from Other PBM Automation Platforms?
Unlike generic automation tools, Ushur’s AI Agents are purpose-built for regulated industries like healthcare and pharmacy benefits.
Key differentiators:
- Domain-specific AI: Trained on PBM, payer, and pharmacy terminology
- Omnichannel experience: Secure engagement via SMS, email, and mobile web (no downloads needed)
- Human-in-the-loop options: Escalate to live agents when needed
- Compliance by design: Built-in guardrails for HIPAA, HITRUST, TCPA, and accessibility requirements
Is AI Secure Enough for PBM Operations?
Every interaction through Ushur is protected by enterprise-grade controls:
- HIPAA & HITRUST certified
- AES-256 encryption in transit and at rest
- Zero data retention unless required
- Accessibility compliance: ADA, WCAG, and Section 508
- Continuous monitoring and live supervision for AI accuracy
These safeguards enable PBMs to innovate confidently while protecting PHI and PII across all channels.
Case Study: How a PBM Transformed Member Engagement with Ushur
A mid-sized Pharmacy Benefit Manager relied on manual outreach for prior authorization denials, refill reminders, and feedback surveys. Staff spent hours on phone calls, emails, and paper notifications—delaying member communication and increasing call center costs.
Using Ushur’s Invisible App™, the PBM automated four high-impact engagement journeys:
- Monthly wellness check-ins
- Automated adherence reminders with refill options
- Prior authorization denial updates with guided next steps
- Real-time member feedback collection
In just weeks, the organization shifted from reactive communication to proactive, HIPAA-secure digital engagement.
Results:
- 25–30% completion across all digital journeys
- Prior authorization resolutions accelerated from days to hours
- Significant call volume reduction, freeing staff for clinical cases
- Improved satisfaction and retention scores
This PBM now delivers faster, more transparent communication while cutting costs and improving medication adherence outcomes.
How Does Ushur Ensure Security and Compliance?
Every interaction through Ushur is protected by enterprise-grade controls:
- HIPAA & HITRUST certified
- AES-256 encryption in transit and at rest
- Zero data retention unless required
- Accessibility compliance: ADA, WCAG, and Section 508
- Continuous monitoring and live supervision for AI accuracy
These safeguards enable PBMs to innovate confidently while protecting PHI and PII across all channels.
Key Takeaways
- PBMs face mounting cost, compliance, and engagement challenges that manual workflows can’t fix.
- Ushur’s AI-powered automation eliminates administrative bottlenecks in prior authorization, benefit verification, and adherence.
- Results include faster therapy starts, lower costs, and stronger member relationships — all within a HIPAA-compliant digital experience.
FAQ: Common Questions About AI for PBMs
Q: What are the first PBM workflows to automate with AI?
A: Start with high-volume, repetitive processes like prior authorization, benefit verification, and refill reminders.
Q: Is Ushur’s platform integrated with PBM systems?
A: Yes, Ushur’s CXA platform integrates securely with claims, CRM, and pharmacy systems.
Q: How fast can a PBM see ROI?
A: Most PBMs report measurable improvements within weeks of deployment.