AI is reshaping Pharmacy Benefit Manager (PBM) workflows from prior authorisation to medication adherence, helping organisations cut costs, speed up therapy starts, and improve member outcomes. As PBMs face rising administrative pressures and growing demands for digital-first engagement, automation platforms such as Ushur’s Customer Experience Automation™ solution are emerging as critical tools to modernise high-volume processes, strengthen compliance, and deliver more transparent, proactive communication across the pharmacy ecosystem.
PBMs continue to operate under intense pressure as rising drug costs, regulatory changes, and increasing member expectations expose the limits of legacy processes.
Manual workflows for benefit verification, prior authorisation, and adherence monitoring consume staff time, delay therapy starts, and frustrate both patients and healthcare providers.
These inefficiencies inflate operational costs and make it harder for PBMs to deliver measurable value to payers.
To address these issues, PBMs are making AI-powered automation a strategic priority. By digitising repetitive tasks and enabling secure, data-driven decisions, PBMs can reallocate staff capacity towards clinical support and more complex member needs. Modernisation also enables clearer communication, faster processing times, and improved adherence outcomes.
Why PBMs are shifting from manual workflows to AI
Ushur positions its AI-powered CXA platform as a direct answer to the operational challenges PBMs face. By reducing manual effort in prior authorisation, benefit verification, and adherence programmes,
PBMs can accelerate therapy starts and reduce reliance on costly call centre interactions. The platform’s HIPAA- and HITRUST-compliant framework also ensures these gains are delivered safely within a regulated healthcare environment.
PBMs sit at the centre of a complex ecosystem that spans pharmacies, providers, plan sponsors, and members.
This central position makes workflow friction especially costly. Medication non-adherence affects around half of Americans, driving an estimated $500bn in avoidable costs each year. Manual prior authorisation delays can add up to $8m per day in wasted spend, while call centre staffing costs mount as teams struggle to keep pace with repetitive queries and administrative backlogs.
AI-powered automation provides a scalable alternative. By removing bottlenecks, PBMs can deliver faster, more predictable experiences that improve satisfaction and strengthen payer confidence.
How AI automation transforms core PBM operations
Prior authorisation is one of the most impactful areas for automation. Ushur’s AI-driven workflows collect required information, validate data against PBM systems, and progress requests automatically—reducing turnaround times from days to minutes.
This cuts dependence on faxes, emails, and phone calls while providing real-time status updates to providers and members.
Medication adherence also benefits significantly from digital automation. Through SMS, email, or the Invisible App™, Ushur enables PBMs to deliver personalised refill reminders, collect feedback, and uncover barriers such as side effects, cost concerns, or logistical issues.
These insights allow PBMs to intervene earlier, boosting adherence rates and improving clinical and financial outcomes.
Across the industry, the fastest ROI has come from automating workflows with high manual volume and measurable results.
Benefit verification, adherence programmes, and prior authorisation have delivered improvements such as 42% lower call centre volume, faster authorisation resolutions, and 25–30% completion rates across automated member journeys. These gains translate directly into stronger retention, better payer satisfaction, and lower operational spend.
Ushur differentiates itself through domain-specific AI built for healthcare and pharmacy benefits.
Its models are trained on PBM terminology, support omnichannel engagement without app downloads, and include human-in-the-loop options when manual review is needed. Compliance with HIPAA, HITRUST, TCPA, ADA, and WCAG is embedded from the ground up, enabling PBMs to automate confidently while maintaining regulatory integrity.
Data security remains central to PBM decision-making. Ushur’s platform uses AES-256 encryption, zero default data retention, and continuous monitoring to ensure accuracy and protection of PHI and PII across all digital channels.
Real-world results
A recent PBM case study highlights the tangible impact of Ushur’s technology. Previously reliant on manual phone calls, emails, and mailed notices, the organisation struggled to communicate efficiently with members about prior authorisation denials, refill reminders, surveys, and wellness check-ins. By automating four high-impact journeys through the Invisible App™, the PBM shifted to proactive, digitally driven engagement.
Within weeks, completion rates rose to 25–30%, prior authorisation resolutions dropped from days to hours, and call centre demand fell sharply. Member satisfaction increased as communication became more consistent and responsive, enabling staff to focus on clinical cases rather than repetitive administrative tasks.
The broader industry takeaway is unmistakable: PBMs cannot continue to rely on manual systems to meet rising expectations around cost efficiency, compliance, and engagement. AI-driven automation offers a clear pathway to faster therapy starts, lower operational costs, and stronger member relationships—while maintaining the stringent compliance frameworks required in healthcare. As the PBM landscape becomes more competitive, solutions like Ushur’s CXA platform are becoming central to delivering sustainable, measurable improvements.
Read the full blog from Ushur here.
Copyright © 2025 FinTech Global
