Using data-driven insights to make pharmacy benefits work smarter

Pharmacy benefits are critical to helping people manage chronic conditions, recover from illness and stay well. Dispensing medications and processing claims often are straightforward, but health care is changing.

Treatments are becoming more complex. Drug costs are rising. Members need more support to start, stay on and get value from their medications. And PBMs have opportunities to do more — engaging clinicians, helping members navigate therapies day to day, and giving plan sponsors more visibility into what’s driving cost and care outcomes.

Why the old model falls short

Many traditional — and even newer, niche — PBM approaches struggle with the same core issues: fragmented data, reactive intervention and disconnected member experiences. When information arrives late or lives in silos, you can miss opportunities to prevent disruption and improve adherence.

Members may not fully understand their benefits or know where to turn when they have questions. Pharmacists and clinicians don’t always have access to the health information they need to make optimal decisions. And HR and benefits leaders may not see what’s working, what isn’t and where to focus next.

A clinically led, data‑informed approach

Data is invaluable for reporting, but it’s even more useful as part of an early warning system. Predictive analytics and artificial intelligence (AI), along with human clinical oversight, can help identify:

• Potential nonadherence
• Emerging clinical risk
• Therapy disruptions
• Opportunities to shift to clinically appropriate, lower‑cost options, such as generics and biosimilars
• Potential issues in prior authorization (PA) requests

CVS Caremark processes millions of PA requests each year, with many approved automatically — reducing friction for members and providers alike. When requests do require review, data‑enabled systems help surface the most clinically relevant information, enabling faster reviews while also calling attention to potential concerns.

“By reviewing evidence‑based use, prior authorization helps match the right drug to the right patient at the right cost,” says CVS Caremark Chief Medical Officer Dr. Michelle Gourdine, “For example, in one case, clinical testing did not support the diagnosis driving the request, and working with the physician allowed us to course‑correct — preventing treatment that would have been ineffective or potentially harmful.”

Data insights are only as valuable as what happens next. Pharmacists and clinicians must review and prioritize what the data means and act on it in real time. They must preserve clinical integrity while enabling earlier, more targeted intervention, ideally before a lapse in therapy becomes a larger health issue. 

Personalized support, without losing human touch

Turning data insights into action also requires rethinking how we support members. Engagement isn’t one‑size‑fits‑all. Some prefer convenient digital tools like text reminders, mobile access and self‑service platforms. Others want direct pharmacist outreach or live support at pivotal moments in their care.

Data helps us better understand where members are in their journey — what medications they’re starting, where confusion or disruption is most likely to occur, and when questions are likely to arise. Those insights allow us to anticipate needs and tailor outreach, whether that means proactive digital guidance, timely reminders or a live connection with a pharmacist when it matters most.

Just as important, data helps connect those touchpoints. Members can move smoothly between digital and human support without repeating themselves or starting over. When experiences are cohesive, they feel more personal, more empathetic and more supportive.

Behind the scenes, the same clinical intelligence informs every interaction. That means members receive consistent, accurate guidance regardless of how they engage — and plan sponsors can be confident personalization is grounded in clinical integrity. The result is support that feels individualized, accessible and human, while still operating at scale.

Connected experiences across the journey

That sense of continuity matters because pharmacy benefits don’t exist in a single moment. They touch multiple points in a member’s journey, from onboarding through long‑term chronic condition management. Members who have an email address on file within the first three months show a 2.1% higher medication adherence.^*  When members understand their benefits and next steps, they’re more likely to follow through.

That’s why we’re transforming the member onboarding experience with digital-first tools.  Our guided onboarding experience pops up when a user logs into the app. It helps navigate them through a personalized welcome journey. The tool identifies member-specific actions they may need to take and changes they should know about from the start.

Prioritizing what matters most

Some of the most meaningful innovation happens behind the scenes. For instance, we use automation and intelligent workflows to speed up processes like PA in several ways:

• Smart routing directs requests to reviewers with the right clinical expertise, reducing rework and handoffs
• AI contextualization highlights key clinical details, so reviewers quickly find the most relevant information
• Touchless prior authorization pulls information directly from the electronic health record (EHR), shortening review time for eligible requests
• Smart edits use existing claims and clinical information to avoid unnecessary PAs

The results? Faster decisions and smoother experiences for members and their providers, while maintaining clinical integrity with confidence. Streamlining workflows and improving efficiency also frees up time for our teams to deliver more focused support.

What this means for plan sponsors

Taken together, these shifts deliver meaningful value for employers and health plans. A data-driven PBM approach can help:

• Boost medication adherence and chronic condition management
• Close care gaps
• Improve workforce health and productivity
• Build confidence that cost management efforts continue to support quality care

Clearer, more actionable insights can also help identify engagement trends and adherence opportunities, supporting more informed benefit decisions.

Where we go from here

The future of pharmacy benefits isn’t about choosing between innovation and integrity. It’s about pairing smarter data with a stronger clinical focus and solutions that address real human needs.

When done well, technology fades into the background, quietly enabling pharmacists, clinicians and care teams to do what they do best: help people achieve better health.

Questions to ask when looking for a data-enabled PBM

When you’re evaluating a PBM’s data and digital capabilities, these questions can help:

• Does the PBM use predictive analytics to flag high-risk members early enough to intervene?
• Are member tools intuitive, mobile‑friendly and personalized, with options for human support when needed?
• Is reporting timely and actionable? Can you see trends in adherence, engagement and cost drivers — not just retrospective summaries?
• Can the PBM connect pharmacy benefits to broader care experiences, like well-being and care navigation programs?

The right PBM should feel like an extension of your people strategy — not just a vendor managing transactions.