Fragmented Benefits Are Failing Members

Most employers have assembled a patchwork of vendors, 15 or more in many cases, each operating in its own silo. Members are left to navigate this maze on their own, and the data proves they are not doing it well.

Jon noted that at a recent conference of more than 100 benefits leaders, roughly 95% had filled a prescription in the past 90 days. Scanning across the audience, he estimates that only one or two had ever price-shopped their medication. That statistic captures the core failure: even sophisticated benefits professionals default to whatever pharmacy and price their plan presents, which is problematic when you’re engaging with legacy PBMs.

There are two main drivers of this disengagement: solution fatigue and misused engagement opportunities. 

• Point Solution Fatigue: When everything is a separate app, login, and phone number, members are overwhelmed and disengaged.

• Wasted Pharmacy Interactions: Any touch point with the pharmacy benefit that isn’t interconnected with other vendors is a missed opportunity to guide members toward better outcomes.

Leveraging Pharmacy-Led Navigation and a Transparent PBM 

So, what are plans to do in the face of rampant member disengagement? The solution lies in simplifying the member experience. SmithRx and Transcarent have partnered to transform pharmacy benefits from a series of isolated transactions and disparate systems into a centralized engagement hub that makes member engagement easier than ever before.

For HR leaders, they get the composability and control of separate agreements with best-of-breed vendors, while members get a seamless, ‘one place’ experience.

Centralizing Navigation with Agentic AI

Transcarent's Wayfinding platform uses agentic AI trained on each member's specific benefits package to deliver personalized guidance. Here, artificial intelligence is achieving something that was structurally impossible before in benefits. 

“We've invested over $100 million in our agentic AI solutions. As members are turning to ChatGPT, Claude, and other tools to ask healthcare questions, it's creating potential inconsistencies and invalid advice, as it's not really trained on their specific benefits. With our Wayfinding experience, members can ask anything and it's really integrated into their benefit system to provide access to real-time clinicians and educational opportunities.”

— Jonathan Koval, PharmD, MBA | GM and VP of Pharmacy Care & Weight Health, Transcarent

Bringing Transparency Throughout the Supply Chain

A navigable, interconnected member experience is meaningless if you have the wrong kinds of partners in your benefits stack. Many PBMs counteract any good done by investing in patient navigation through opaque practices such as spread pricing, client cross-subsidization, and vertical integration. 

Having the right PBM partner in your benefit offering is crucial for both cost-containment and member experience. SmithRx operates as a pure-play, totally configurable PBM that doesn't use spread pricing or hidden margins, or have any pharmacy ownership conflicts. Our partnership with Transcarent is enhanced by our mutual commitment to transparency. 

Our dedication to transparency and client-alignment runs deep: our platform-based pricing model gives every client the same great deal, whether the employer has 50 lives or 100,000 lives. We do not ever take any spread, hidden margins, or receive kickback revenue. Every dollar is visible to the plan sponsor, because we only profit from a simple, single administrative fee.

This client-aligned ethos, combined with our proprietary Drug Pathways Engine, which executes real-time clinical and cost optimization that routes members to the best drug at the best price, secures exceptional savings for our clients. All of this is 100% auditable by our clients, bringing much-needed transparency to the pharmacy supply chain.

Utilizing Pharmacy-Led Navigation

One of the most compelling strategies discussed in the episode was using real-time prescription signals to trigger proactive outreach. Instead of waiting for members to find their own way, pharmacy claims data triggers immediate, relevant connections such as:

• Filling an oncology medication triggers connection to an oncology nurse navigator

• Antidepressant prescription pickup triggers outreach to mental health and EAP resources

• Antibiotic fill triggers a 48-hour check-in with a virtual care provider

• GLP-1 prescription fill triggers enrollment in weight management solutions

Benefit partners each have a ton of data at their disposal, and when they can work in tandem, rather than in silos, the member experience can be totally transformed to one where patients, at a potentially difficult moment, don't have to figure out a complex system for themselves. Instead, benefits vendors can pass helpful information to automate the best next step for that member and their outcome.

The Future of Pharmacy Benefits: Upstream Interception

The next frontier of pharmacy benefits will bring PBMs closer to members than ever before. The key to reducing friction from necessary clinical functions, like prior authorization, is to intercept prescriptions before they reach the wrong pharmacy or wrong drug. This includes provider education at the point of prescribing and putting patients in the driver’s seat of their pharmacy experience, so they can make informed decisions.  

"That's really the power of pharmacy-led navigation. We take the real-time signal of a claim, we understand what broader benefits are available to the member, and we outreach at the right time to really help inform them and educate them, not just on their potential pharmacy options, but on their broader benefits."

— Jonathan Koval, PharmD, MBA | GM and VP of Pharmacy Care & Weight Health, Transcarent

Frequently Asked Questions About SmithRx & Transcarent

Did Transcarent acquire SmithRx?
No. Transcarent and SmithRx formed a strategic partnership. SmithRx remains an independent, pure-play PBM. The partnership brings SmithRx's core member-facing functions into Transcarent's 'One Place' navigation platform.

How do Transcarent and SmithRx technically work together? Is AI involved?
Members access their benefits through the Transcarent app, which surfaces data from SmithRx in real-time. Agentic AI personalizes guidance based on each member's specific plan design, pharmacy options, and clinical profile.

Why is pharmacy the anchor for benefits navigation?
Pharmacy is the most utilized healthcare benefit. Members fill prescriptions monthly, compared to just three to four provider visits per year. That frequency creates a steady stream of real-time signals. Each one of those signals is an opportunity to connect members with the right clinical and benefits resources at exactly the right moment.

Pharmacy-led navigation, powered by transparent PBM practices and real-time claims data, turns the most frequent healthcare touchpoint into a centralized hub for better outcomes and lower costs. Watch the full episode, or download our partnership overview asset.

Explore the full Full Disclosure series for more expert conversations on pharmacy benefits transparency.