Member experience makes or breaks how people feel about their benefits, but it's one of the hardest things to measure when you're evaluating a pharmacy benefit manager (PBM). Ask three finalists for their call center metrics and you'll get three different definitions of "answered," "resolved," and "satisfied." Without a shared scorecard, those numbers don't tell you who performs better, just who reports more generously.

When metrics aren't comparable, sorting out the mess falls on HR. Unresolved service questions don't stay hypothetical, they turn into escalations after go-live, and they shape how employees feel about the plan day to day. A sound comparison needs three things: metrics defined the same way for every finalist, evidence you can verify against your own plan, and contract terms that keep service accountable once it's live.

Here’s how to build that comparison.

What Separates a Strong PBM Call Center Experience for Members

A PBM with an exceptional member experience with their call center resolves the member's question on first contact, reaches clinical or benefit expertise when needed, and reports performance employers can check. Speed of answer gets the member to a person. The rate of resolution determines whether the member has to call again or has further hiccups taking full advantage of their benefit.

Member calls to a PBM can involve coverage questions, prior authorization status, claims rejected at the pharmacy, and pharmacy changes. Getting swift, accurate answers to these questions are often make or break in the member's perception of their pharmacy benefit. It's critical that the reps answering the phone are experts on your benefit.

Industry wide, there has been a push to make patient experience a focus of PBM contract negotiations and partnerships. For employers, PBM customer service is one of the most direct places to apply that advice. It can mean the difference between a seamless benefit experience versus one that constantly taps HR for escalations.

Call Center Performance Metrics That Matter

Every PBM will tout that they have an exceptional member experience and use some version of the metrics below. While the names of each metric can match across RFP responses, definitions may differ. It's critical to push PBMs to clearly define the methodology behind the metrics they report before comparing across vendors.

No single metric shows quality. A fast answer followed by a transfer and a callback still looks strong on speed even when the member needed three contacts for one question. It's important to not evaluate metric by metric in a vacuum, but rather the picture these performance metrics paint holistically.

How to Verify What a PBM Reports

Self-reported metrics are only as useful as their definitions and the population behind them. Verification starts in the RFP and continues through finalist meetings.

Standardize Definitions in the RFP

Give finalists a required metric template that states your definitions, so every response measures the same thing. Ask each PBM whether its figures cover its full book of business or a client population like yours. Ask which measurement period each figure uses, since a number without a stated population and period can't be compared with another PBM's number.

Ask for Plan-Level Reporting

Ask each finalist for a sample of the recurring member service report it would provide for your plan, with its cadence and detail. Plan-level results show what your members experience, while a book-of-business average can mask it. How a PBM handles experience metrics in PBM reporting also shows whether service data will reach you in a form you can act on.

Test the Experience Directly

Walk finalists through realistic scenarios: a claim rejected at the pharmacy, a pending prior authorization, a mail-order delay, and a dependent coverage question. Ask the PBM to explain how an agent would handle each one and where escalation goes. Listen for who owns each step and how the member learns what happens next.

Then ask current client references how often member questions reach HR. References describe daily operations that a finalist presentation can't show.

Questions to Ask About Call Center Experience in Your Next RFP

Resolution depends on what sits behind the phone line: data access, clinical routing, and follow-through. These PBM RFP questions show how a finalist's call center connects to the rest of its operation.

• Who answers member calls, and do agents work in the PBM's own operation with access to claims and benefit data?

• Is your Member Support team in-house or contracted out? Where are they based: off-shore or on-shore?

• How do agents handle a prior authorization question within the utilization management process, including status and next steps?

• Who closes the loop after the call, and how is the member notified of the outcome?

• Which channels, such as phone, chat, and in-app, can members use, and during what hours?

• How does staffing change at open enrollment, at go-live, and during formulary changes?

Specific answers name owners, systems, and handoffs. General answers can signal a call center that works as a separate message-taking layer, with resolution happening somewhere the member can't see.

Writing Member Service Into the Contract

PBM performance guarantees turn RFP answers into tools for accountability. For each service metric you guarantee, it's worth asking your legal team whether the contract should address terms like:

• The metric definition, using the same wording as your RFP template

• The measurement method and data source

• The measurement period and reporting cadence

• The population measured, limited to your plan's members

• Your verification and audit rights over service data

It's worth setting targets from your plan's current baseline and needs rather than borrowing an industry number with an unknown definition behind it. And when a finalist offers response-time commitments across channels, it's worth asking your legal team to help confirm what each one measures and what happens after a miss. Defined guarantees give the benefits team a documented basis for ongoing oversight of member service.

How SmithRx Approaches Members' Call Center Support Experience

At SmithRx, we're proud to say our member support is 100% on-shore and in-house, so the teams answering calls are experts in the benefit we administer. When a question needs coordination, our teams help members work through next steps and handle coordination with prescribers and pharmacies.

Members can reach our support by phone, web chat, and email. The SmithRx Member Portal and Mobile App provide up-to-date prior authorization and claim updates to make status visibility easy.

In 2025, SmithRx members waited less than 21 seconds on average to reach support. On the same internal measures and timeframe, members rated their ease of getting help 4.6 out of 5.

For employers, this means employees have one connected place to get help and are met with knowledgeable, timely service. The right PBM member call center for your plan is the one whose results you can define, check, and enforce for your own members. Treating service as a measured contract term gives benefits leaders a comparison grounded in their plan instead of someone else's ranking.

Want to learn more about SmithRx's commitment to exceptional, industry-leading member service? Speak to one of our benefits experts, today.

Frequently Asked Questions

What is a good average answer speed for a PBM member call center?

Across the healthcare industry, average hold times can range up to over 4 minutes, but this differs sizably with subsets like PBMs. Set the target from your plan's current baseline.

Should a PBM's member call center be in-house or outsourced?

In-house teams typically offer stronger results because agents have direct access to claims data, deeper training on your specific benefit design, and established escalation paths to clinical staff within the same organization. When evaluating finalists, ask outsourced providers to demonstrate how they replicate that level of integration and expertise before considering their model as equivalent.

Do digital member tools replace the PBM call center?

Portals and apps handle lookups and status updates, while people handle exceptions and clinical questions. Evaluate how the two connect, including whether agents and digital notifications draw on the same case information.