Benefits leaders comparing one pharmacy benefit manager (PBM) with another on member experience likely encounter familiar evidence time and time again: satisfaction rankings, call-center wait time metrics, and app demos. Those signals are typically associated with routine fills, where a member picks up a maintenance medication and moves on. They say little about the claims that put the most weight on a PBM's process.

Commonly prescribed medications are likely not the claims putting strain on your plan or your members. Specialty prescriptions where prior authorization, specialty pharmacy access, high costs, and manufacturer assistance are required often create friction for the member. With multiple workflows and responsible parties at each step of the claim process, a delay anywhere may quickly escalate, putting stress on the HR team and leaving a member without their medication.

When evaluating a potential PBM partner, it's important to look closer at member experience. Think of examining routine fills as getting your vitals checked at your doctor. It's important, but often doesn't paint a full picture. Then, digging into the member experience for things like specialty medications is akin to getting an MRI: it shows a more complete picture of the 'health' of the PBM's member experience.

By walking in the shoes of your most in-need members and examining the specialty prescription claims process, you gain a clearer overall picture of the PBM's experience.

Why Specialty Claims Are a Clear Test of a PBM's Member Experience

The processes for specialty medications will never be identical to those for common, low-cost medications. Without proper clinical oversight, it can result in misuse and overspend for your plan. However, the right PBM partner can demonstrate how it moves a specialty member from prescription to first fill and how it keeps that member on therapy at the lowest net cost that is also clinically appropriate.

Specialty medications are often high cost and used to treat complex conditions such as cancer, autoimmune disorders, and rare diseases. A routine fill travels seamlessly from a prescriber to the pharmacy, with the member never knowing what PBM processes run in the background. A specialty fill, in contrast, layers on a clinical review, the need to fill at a specialty pharmacy, and often a manufacturer copay assistance program. These different levers, which are designed to curb costs for the plan and member, add complexity and points of friction.

For employers, each specialty prescription combines high plan cost with several points where a member may need help. How the PBM manages those handoffs shapes employee experience, HR workload, and ultimately pharmacy spend.

Access: How the PBM Manages Specialty Utilization

Prior authorization and step therapy are utilization management (UM) tools a pharmacy benefit plan requires before covering certain specialty drugs. Both are designed to confirm that a therapy is clinically appropriate and cost-effective before coverage applies. How a PBM runs them varies by vendor and by plan, so your evaluation must focus on the process.

Start with ownership. Ask who writes the clinical criteria and how often they are updated, and who reviews requests: pharmacists, other clinicians, or both. Inquire how turnaround is measured, from which event to which event, and whether standard and urgent requests are reported separately. Then ask what the escalation and appeal path looks like when a prescriber disagrees with a decision.

In a February 2025 viewpoint, Business Group on Health argued that UM needs greater transparency and reporting about its impact on patients. That view translates into a practical RFP ask. Request UM reporting on member impact, including turnaround times, approval and redirect outcomes, and appeals alongside projected plan savings.

Member visibility is equally critical. Verify whether members and HR can track prior authorization status in real time, or whether members first learn about the outcome of coverage decisions when they arrive at the pharmacy counter.

Channel: Where Specialty Prescriptions Get Filled

Where a specialty prescription is filled affects what the plan pays and what the member experiences. Delivery timing, refill coordination, and whom the member calls with a question all depend on the dispensing channel.

Some PBMs own or are affiliated with specialty pharmacies, and often design benefit structures that require members to fill at these specialty pharmacies. Learn whether the PBM owns or is affiliated with any specialty pharmacy, how much network flexibility your plan has, how the PBM decides where a specialty claim is routed, and who reviews that decision.

Federal law is moving toward the same questions. Under the Consolidated Appropriations Act, 2026, PBMs serving group health plans will be required to report claims by dispensing channel, including specialty pharmacy. PBMs with an affiliated pharmacy will also have to disclose affiliated dispensing and benefit designs that encourage or require fills at those pharmacies.

These requirements apply to future plan years, and employers do not need to wait for them. Seek channel and affiliation data in your RFP now, so you can compare PBMs on the facts the law will eventually require.

Cost: What Members Pay and How Assistance Is Handled

When a plan applies coinsurance to a specialty tier, the member pays a percentage of the allowed amount, so their share rises with the drug's price until the plan's out-of-pocket limit is reached. Manufacturer copay assistance can offset what members owe. How the PBM identifies eligible assistance, applies it, and coordinates it with the plan's cost sharing affects what members pay at the counter.

To learn more, ask how the PBM handles each step of assistance. How are members notified when savings are available? Who helps members complete enrollment paperwork for a manufacturer program? How does assistance appear in employer reporting, so you can see what the plan paid separately from what assistance covered?

Alternatives: How Biosimilar and Lower-Cost Switches Are Supported

Biosimilars and other clinically appropriate alternatives are a lever for managing specialty cost. In National Alliance's 2025 Pulse of the Purchaser survey, 65% of the employers and purchasers surveyed reported already promoting or including biosimilars on their formulary. When most surveyed purchasers already take that step, the more useful comparison is how a PBM executes the switch.

A switch that looks simple on a formulary list can still need the prescriber. The FDA notes that, depending on state law, a biosimilar typically has to be prescribed by name, while an interchangeable biosimilar may be substituted at the pharmacy without the prescriber's involvement. Therefore, if a switch is required, someone has to contact the prescriber, explain the change to the member, and protect continuity of care while the new therapy starts.

Ask the PBM to show its switch support: who does the outreach, what the member hears, and how many members stay on the alternative.

Specialty Questions to Put in Your PBM RFP

The table below turns each stage of the specialty journey into reusable RFP language.

How SmithRx Approaches the Specialty Member Experience

A member with a specialty prescription needs the right drug, pharmacy, and price to line up, often with a prior authorization in the middle. Our experience is designed to manage all of these considerations seamlessly.

SmithRx's Drug Pathways Engine evaluates every claim to optimize drug selection—identifying clinically appropriate generics, biosimilars, and therapeutic alternatives. It also locates the lowest-cost source among retail, mail order, and specialty pharmacies while identifying available cost modifiers such as manufacturer savings programs or rebates. Since we do not own pharmacies or use preferred network arrangements to influence where a claim is directed, we remain aligned with the best interest of the plan and member.

Some pathways apply automatically, and others need a supported next step. Members can follow each step through our Member Portal. They receive prior authorization status updates and savings alerts by email, text, and in the Member Portal Notification Center. That visibility helps members understand where a request stands and what to do next.

Our internal data showcases how the review process performs. In 2025, our standard prior authorization turnaround time averaged 3 days, and urgent requests averaged under 24 hours. Both figures are averages across all prior authorization requests, not specialty requests alone.

Specialty is where a PBM's model, network channels, and member support become visible to members and HR at the same time. Walk one specialty prescription through each PBM you are considering, ask for evidence at every handoff, and choose the partner whose answers hold up.

Want to learn more about how SmithRx delivers exceptional experiences and savings for specialty claims? Speak to a member of our team today.