PBM Mirage
When Volume Poses as Value
Let’s call it what it is.
For too many PBMs, “pharmacy benefit management” has become a misnomer. They don’t manage pharmacy benefits—they manage fills. They don’t guide care—they automate approvals. And the endgame isn’t better outcomes—it’s faster fills, higher volume, and margin on the move.
It’s not care. It’s commerce—disguised in acronyms.
This is the fill-and-bill industrial complex, where injured workers become units of throughput, and clinical nuance is paved over by protocols written to prioritize profit.
At Prodigy, we’ve seen it up close:
Formularies that push brand-name drugs with rebates, not outcomes
Mail order programs that reward speed over scrutiny
“Clinical programs” that are just glorified prior auth queues
Meanwhile, patients with polypharmacy risks, behavioral health flags, or complex comorbidities are run through templated workflows—zeroing out what actually matters: clinical intervention.
At Prodigy, we do it differently:
✅ Our pharmacists aren’t hidden behind policies—they’re embedded in every complex case
✅ We flag risky combinations and step in early—before costs explode
✅ We call physicians directly, provide evidence-based alternatives, and track outcomes post-intervention
✅ We don't just audit prescriptions—we own clinical performance
Because the real job isn’t filling scripts—it’s preventing the wrong ones, adjusting the risky ones, and advocating for what’s best for the patient.
Here are three ways to tell if your PBM is just pushing pills under the guise of management:
Do they intervene—or just authorize?
If clinical review takes less time than brewing coffee, it’s not review. It’s rubber-stamping.Do you know which patients were actually helped?
Or just how many were processed?Do your pharmacists lead—or follow the script?
Because if tech teams are setting your clinical policy, don’t expect care—expect compliance theater.
Pharmacy benefit management isn’t about throughput. It’s about thoughtfulness, helping payers and improving patient outcomes.
📞 Let’s talk. If you’re ready to trade volume for value, and autopilot for actual oversight, Prodigy is ready to show you what real care looks like. Call me for a virtual consult. No pressure. Just clarity. I promise—it’ll be worth your while.
About P4P
A Strategic Dose of Clarity in a Noisy PBM Market
Written by Prodigy CEO Del, P4P delivers sharp, consultative insights for decision-makers who are tired of legacy models, hidden costs, and passive vendors. Each piece is a prescription—cutting through the noise to reveal what actually drives performance in pharmacy benefit management.
No fluff. No spin. Just insight that pays off.
