Artificial intelligence (AI) is revolutionizing healthcare, and pharmacy benefits management (PBM) is no exception. Employers are increasingly leveraging AI-driven solutions to enhance cost control, improve medication adherence, and optimize plan design. However, with innovation comes responsibility. Employers must navigate AI’s potential while ensuring transparency, accountability, and ethical decision-making in pharmacy benefits management.

The Role of AI in Pharmacy Benefits Management

AI has introduced a range of advancements in PBM, from predictive analytics that forecast high-risk patients to automated prior authorizations that streamline approvals. Predictive analytics help identify patterns in claims data to anticipate high-cost drug utilization and recommend proactive interventions. Automated prior authorizations expedite approvals by analyzing clinical guidelines and patient history, reducing delays and administrative burdens.

AI also plays a critical role in fraud detection, flagging unusual prescribing or billing patterns to combat waste and ensure cost-effective care. Additionally, AI-driven adherence tools send reminders and provide personalized insights, leading to better health outcomes and reduced hospitalizations. Finally, dynamic formulary management continuously assesses drug effectiveness and costs, enabling real-time adjustments to optimize affordability and quality.

Balancing Innovation with Employer Accountability

While AI presents numerous opportunities, employers must exercise due diligence to ensure ethical implementation. Transparency is key—employers should demand visibility into how AI models determine drug coverage, formulary recommendations, and prior authorization approvals. Understanding these algorithms helps prevent biased or cost-driven decisions that may negatively impact employees.

Data privacy and security are paramount. Since AI relies on vast amounts of sensitive health data, employers must ensure their PBM partners comply with HIPAA and other privacy regulations to protect employee information from breaches and misuse. Additionally, while AI can drive cost reductions, employers must ensure savings are not achieved at the expense of patient outcomes. Regular audits and independent reviews of AI-generated decisions can prevent unethical cost-cutting measures that deny employees access to necessary medications.

Employers should also maintain human oversight in AI-driven decision-making. AI should augment—not replace—human expertise. Working with PBMs that integrate AI insights with clinical pharmacist reviews ensures nuanced decision-making that accounts for individual patient needs. Furthermore, AI should align with fiduciary responsibilities, ensuring decisions prioritize patient health, cost-effectiveness, and long-term value rather than short-term financial gains.

Questions Employers Should Ask Their PBM About AI

To ensure AI is used responsibly, employers should ask:

• How does AI influence formulary and coverage decisions?
• What safeguards are in place to prevent bias in AI-driven benefit determinations?
• How does AI-driven cost-saving align with clinical best practices?
• What level of human oversight is included in AI decision-making?
• How is employee data protected within AI-driven PBM systems?

Conclusion: The Future of AI in Pharmacy Benefits

AI is set to play an increasingly vital role in pharmacy benefits management, offering efficiency, cost savings, and improved patient care. However, employers must remain vigilant, ensuring AI-driven decisions align with ethical, transparent, and employee-centric strategies. By demanding accountability from PBMs and maintaining oversight, employers can harness AI’s potential while safeguarding their workforce’s health and financial well-being.

As AI continues to evolve, employers must stay informed, engaged, and proactive in their approach to pharmacy benefits. The key to success lies in balancing technological innovation with the fiduciary responsibility to provide fair, transparent, and effective healthcare benefits for employees.