There are moments in healthcare when the difference between “covered” and “accessible” becomes painfully clear.
It is not always about whether a therapy exists. It is whether the path to that therapy is navigable. Fast enough, coordinated enough, and clear enough for a patient and care team already carrying far more than they should.
That reality came into sharper focus in Episode 54 of Unscripted: The AMCP Podcast, where our President and CEO, Jeff Dunn, PharmD, MBA, discussed the evolving landscape for HER2-positive biliary tract cancer and what it means for managed care. In the conversation, Jeff came back to a principle that is both clinical and practical:
“The key here is right drug, right patient, right time… If we can find the right drug and get the patient on that drug sooner, we will have better outcomes, specifically overall survival.”
He was speaking about rare cancer care, but the point holds across pharmacy benefits more broadly.
When the stakes are high, the pharmacy benefit should be coordinated with the medical benefit and easier to navigate.
Rare disease is not a statistic to the person living it
About 1,800 adults in the U.S. are affected by advanced or metastatic HER2-positive BTC—only .0005% of the population.
Managed care leaders often start with a population view: prevalence, evidence, expected utilization, total cost of care. That is responsible stewardship.
Rare conditions remind us of something equally true: even when the patient populations are small, the human and operational impact can be substantial . Delays in care are not abstract. They show up as missed work, long calls, extra appointments, and unanswered questions.
The podcast discussion highlighted the importance of biomarker testing and molecular profiling. In cancers like biliary tract cancer, the ability to match therapy to a patient can depend on identifying actionable biomarkers. When that information comes late, everything downstream becomes harder. More trial-and-error. More waiting. More stress for patients and for the teams trying to help them.
Once a therapy is identified and the prescription pathway begins, the pharmacy benefit can either add friction or reduce it.
The quiet problem is the accumulation of friction
In complex care, delays rarely come from one dramatic denial. More often, they come from a dozen small disconnects:
- The member is unsure where to start and who to call.
- The provider office spends hours chasing requirements across multiple parties.
- Coverage criteria are unclear, inconsistent, or hard to locate.
- Prior authorization becomes a back-and-forth rather than a predictable pathway.
- A specialty medication is approved, but the steps to start therapy are still slow.
People don’t experience pharmacy benefits as policy documents. They experience them as moments. A phone call. A refill. An onboarding process. A surprise cost. A delay they can’t explain.
When treatment stalls, the member doesn’t call it “utilization management.” They call it another week of waiting.
Guardrails matter. Clarity matters too.
“Right drug, right patient, right time”
That phrase is easy to agree with. The harder part is building a pharmacy benefit that supports it.
For a PBM, “right time” comes down to practical work done consistently. Requirements need to be clear and easy for provider offices to follow. Prior authorization should be predictable and responsive Coverage communication should be written in plain language. And members should be able to understand affordability options and next steps without having to decode the process.
None of that replaces clinical care. It supports it by making the pharmacy benefit less of a hurdle.
Cost matters, and incentives shape the path
o responsible plan sponsor can ignore pharmacy cost. High specialty drug costs are real. Employer budgets are real. Member affordability is real.
But “cost management” can mean very different things depending on how a PBM is structured. Leaders are not just asking, “Is this expensive?” They are asking, “Do we understand why it is expensive, and are the incentives aligned with the plan and the member?”
That is where transparency and a 100% pass-through PBM model matter.
When negotiated value is passed through, more of it stays with the plan. That creates options. Plans can reinvest in parts of the pharmacy benefit that members and providers actually feel, including reducing unnecessary member cost exposure where it improves adherence, strengthening programs that reduce avoidable waste, improving service and responsiveness at the point of need, and supporting smoother specialty starts and fewer delays.
This is one of the clearest ways to pursue both goals at once: managing spend responsibly while protecting the member experience.
The takeaway for organizations evaluating PBM partnership models
If you are evaluating options like a private label PBM or joint venture PBM, you are not just choosing a vendor. You are choosing an operating model that will shape how transparent your pharmacy spend truly is, how aligned PBM incentives are with your goals, how members experience coverage at the pharmacy counter, how specialty coordination and support work in practice, and how much flexibility you have to tailor pharmacy programs over time.
If your organization’s mission includes caring for people, most do, the question becomes:
Does your PBM structure help you reinvest value into members, or does it siphon value away from them?
That is why we connect transparency, pass-through economics, and clinical rigor. Not as buzzwords, but as building blocks for a pharmacy benefit that is easier to navigate and easier to trust.
Pharmacy benefits that show up for people
Jeff’s comments on Unscripted were made in the context of a rare cancer. Still, it captures a standard that applies everywhere: when we reduce delays and confusion inside the pharmacy benefit, people have a better chance to benefit from the therapies available to them.
A pharmacy benefit should not add weight to an already heavy journey—t should make the next step clearer.
Because when care is complicated, people do not need more complexity. They need a system that helps them reach the treatment they need.
