Feeling stuck with your PBM? Ask these 6 questions before you switch

Rising drug costs, opaque contracts, and growing regulatory scrutiny are prompting more employers to take a closer look at their current model. For HR leaders, the question is no longer if they should switch. It’s how to do it without creating chaos for their employees.

Six questions every HR leader needs to ask

Too often, a PBM transition is treated like a data handoff. But when HR is equipped with the right process and visibility, the experience shifts from reactive to proactive and from chaotic to controlled.

The goal is not just to change vendors. It is to build a bridge between your current setup and a future state that works better for your employees. That takes foresight, pressure testing, and clear accountability.

Ask prospective PBMs these six questions before you sign the contract:

1. How will you match our current formulary? Coverage gaps create chaos. Your PBM should be able to mirror your current formulary, or clearly explain where and why they cannot, with mapped alternatives and clear employee communication.
2. Can you replicate our existing pharmacy network? Forcing employees to switch pharmacies is one of the most personal and avoidable disruptions. Your PBM should match the existing network (or better yet, expand it).
3. Will you review our summary plan description and claims data to identify gaps or mismatches? A good PBM spots discrepancies early and helps fix them before they become legal or operational landmines.
4. What’s your process for converting specialty medications? Specialty medications aren’t plug-and-play. They require coordination across doctors, patients, and pharmacies. Your PBM should explain who handles what, and when.
5. How and when will our employees be notified and supported during the switch? Employees need clear, timely, actionable communication. That means more than just getting ID cards in hand. The PBM should notify pharmacies ahead of time, ensure prescriptions are transferred without disruption, and equip employees with simple FAQs and a real person they can call for support.
6. What does your support model look like in the first 30 days? The first 30 days will make or break the transition. Expect daily reject reviews, proactive pharmacy outreach, real-time troubleshooting, and complete transparency. Anything less is a red flag.

Seamlessness should be invisible

When PBM transitions are done right, your employees do not notice.

They walk into the pharmacy, fill their medications, and move on with their day. Their doctors know where to send prescriptions. They have their ID cards before they need them. Their pharmacy has already been notified, and prescriptions have been transferred in advance, so employees avoid delays and confusion at the pharmacy counter.

Related: 'Fully transparent' PBMs may not cut costs, Segal health expert says

That kind of transition is not luck. It is intentional design. It is the result of HR and the PBM working through every decision, data file, and employee scenario to ensure the handoff is smooth, timely, and invisible to the people who rely on it.

You’re not stuck. You’ve just been let down.

Too many PBMs have normalized a low standard for implementation, treating disruption as inevitable instead of unacceptable. That is why HR leaders feel trapped. It is not because they are unwilling to switch, but because they have seen how badly transitions can go.
But better is possible. You do not have to settle for confusion, complaints, or costly handoffs. You can expect more: clarity, control, and continuity. With the right partner, your next transition can be better starting on day one.

David Blair is the CEO of LucyRx, an independent, next-generation pharmacy benefit manager redefining prescription care. A healthcare innovator and industry disruptor, David has more than 25 years of experience helping organizations lower costs, improve access, and deliver better outcomes through smarter pharmacy benefit management.