Pharmacy benefit managers occupy a critical — and often invisible — position in the U.S. healthcare system. They negotiate drug pricing, design formularies, process prescription claims, and administer pharmaceutical benefits for employers, health plans, and government programs. According to the Drug Channels Institute's 2025 PBM Industry Report, the three largest PBMs processed a combined 5.1 billion prescription claims in 2024. Even for smaller regional and specialty PBMs, claim volume runs into the hundreds of millions annually. The operational infrastructure required to support that volume — claims adjudication support, member services, plan sponsor relations, and compliance administration — is enormous, and VAs are increasingly embedded in it.
Claims Processing Support: Handling the Human Layer
Modern PBM claims adjudication is largely automated, but exceptions, rejections, and manual review flags require human intervention. Prior authorization requests, step therapy documentation, formulary exception requests, and rejected claims requiring resubmission are all tasks that need timely human attention — but don't necessarily require a licensed pharmacist.
VAs trained in PBM claims workflows support these functions by gathering and organizing documentation for prior authorization submissions, tracking the status of pending authorization requests, notifying members and prescribers of authorization decisions, and preparing resubmission packets for rejected claims. A 2025 report from America's Health Insurance Plans (AHIP) found that organizations with dedicated prior authorization support staff processed requests 38 percent faster than teams relying on prescribers and pharmacists to manage the workflow independently.
"Prior auth is where our bottleneck was," said Sandra Kwon, Director of Clinical Operations at a regional PBM. "We had pharmacists spending 30 percent of their time on documentation and follow-up that a well-trained VA could handle. Once we delegated that, our pharmacists got back to actual clinical work and our auth turnaround times dropped by nearly half."
Member Services: Answering the Questions That Never Stop
PBM member services departments handle a continuous stream of inquiries: drug coverage questions, copay tier explanations, mail-order pharmacy enrollment, claims status requests, and formulary alternative guidance. Many of these inquiries are routine and can be handled without clinical expertise — they just need someone knowledgeable, patient, and available.
VAs handle first-line member inquiries via phone, chat, and email. They look up benefit information in member portals, explain copay and deductible information, process mail-order pharmacy enrollment requests, check claims status, and escalate complex clinical or coverage disputes to licensed staff. According to J.D. Power's 2025 Pharmacy Benefit Experience Study, member satisfaction with PBM services is most strongly predicted by first-contact resolution rate — and VAs significantly improve that metric by handling the high-volume, low-complexity tier of inquiries.
PBMs also service plan sponsors — HR and benefits teams at employer clients — who have their own set of administrative needs: reporting requests, formulary change questions, and member data inquiries. VAs manage plan sponsor communication queues, providing timely responses and escalating technical plan design questions to account managers.
Administrative Operations: The Foundation of PBM Operations
The back-office work at a PBM is substantial. Contract management with health plans and employer groups involves tracking renewal dates, compiling performance reporting, and coordinating data exchanges. Regulatory compliance requires maintaining documentation libraries, tracking state PBM regulation requirements, and preparing filings. Finance operations involve reconciling rebate payments, auditing claims-based invoices, and tracking accounts receivable.
VAs absorb the administrative layer of these functions: maintaining contract calendars and renewal alerts, compiling monthly performance reports from data exports, tracking open items on compliance documentation, and reconciling financial records against claims data. According to the Pharmaceutical Care Management Association (PCMA), PBMs that invested in operational support infrastructure — including virtual and remote staff — reduced administrative cost per claim by an average of 12 cents compared to peers relying on in-house-only staffing.
Deploying VAs in a HIPAA-Regulated Environment
PBMs handle significant protected health information, and VA deployments must be structured accordingly. VAs working with member data should operate under a signed Business Associate Agreement, use secure communication and data access platforms, and complete HIPAA training before beginning member-facing work. These safeguards are standard practice for reputable VA providers serving healthcare organizations.
For PBMs looking to expand operational capacity without proportional headcount growth, Stealth Agents offers virtual assistants with experience in healthcare administrative workflows, member services, and regulated data environments.
The Margin Imperative for PBMs
In a sector where pricing pressure from clients and regulators is intense, operational efficiency is a survival issue for PBMs. Virtual assistants represent one of the highest-leverage cost management tools available — delivering meaningful labor cost reductions while improving the speed and quality of member, prescriber, and plan sponsor service.
Sources
- Drug Channels Institute, PBM Industry Report, 2025
- America's Health Insurance Plans (AHIP), Prior Authorization Benchmark, 2025
- J.D. Power, Pharmacy Benefit Experience Study, 2025
- Pharmaceutical Care Management Association (PCMA), PBM Operations Cost Benchmark, 2025