Beyond Service: The Strategic Value of PBM Call Centers

September 15, 2025

Why Call Center Excellence Matters in Pharmacy Benefit Management

In today’s health care landscape, the call center is more than a service desk. For a pharmacy benefit manager (PBM), it is a critical touchpoint that shapes member satisfaction, client trust, and even Star Ratings performance. Every interaction, whether it’s answering a question about formulary coverage, assisting with a prior authorization, or helping a member navigate cost-saving opportunities, directly influences outcomes. A member’s perception of their health plan is often defined by a single phone call, making this channel a powerful determinant of loyalty and retention. When representatives provide accurate, empathetic, and timely assistance, they don't just solve a problem; they build confidence in the plan's ability to support its members' health journey. This trust is foundational to long-term success for both the PBM and its health plan partners.

PerformRx’s Customer Care Center (CCC) has positioned itself as a leader in delivering high-touch, high-quality member support. Backed by robust performance metrics and a continuous improvement culture, the CCC ensures that both members and clients receive the right information, at the right time, through the right channel.

Setting the Standard: CMS Requirements and Industry Benchmarks

The Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D call centers to meet stringent performance standards, including answering 80% of incoming calls within 30 seconds and maintaining abandonment rates at or below 5%.¹ These benchmarks are in place to guarantee that Medicare beneficiaries, who often have complex health care needs, can access critical information without undue stress or delay. Meeting these standards is not simply a matter of compliance; it is a marker of a PBM’s operational health and commitment to its members. Across the broader health care industry, average hold times can reach 4.4 minutes, and first call resolution (FCR) rates often hover around 52%.² These averages highlight a widespread gap between what is expected and what is often delivered.

By comparison, “good” call centers, those operating in the top performance tier, achieve FCR rates between 70% and 79%.³ This difference is not just about service quality; research shows that every 1% increase in FCR can result in significant cost savings and improved member retention.³ For health plans, a higher FCR rate translates directly to a reduction in repeat calls and a decrease in administrative costs, all while enhancing the member experience and strengthening the plan’s reputation.

PerformRx CCC: Exceeding Expectations

PerformRx’s CCC consistently outperforms national health care benchmarks in speed, accuracy, and resolution rates. Key performance areas include:

• Fast Response Times: Calls are answered well within CMS standards, reducing wait times and improving member experience. This efficiency is critical during peak enrollment periods and during times of urgent need, ensuring members always have a reliable point of contact.
• High First Call Resolution: The CCC’s resolution rates exceed health care averages, minimizing member frustration and the need for follow-up contacts. This prevents a single issue from becoming a prolonged source of discontent and demonstrates the team's expertise.
• Low Abandonment Rates: Abandonment is kept well below CMS’s 5% threshold, even during peak call volume periods. A low abandonment rate is a powerful indicator of member satisfaction and trust, as it signals that members feel their time and concerns are valued.

This performance is the result of a disciplined approach to workforce management, call routing, and real-time monitoring, ensuring that staffing levels align with demand and that calls are directed to the right representatives on the first attempt. The CCC's robust infrastructure and proactive management prevent common bottlenecks that can derail service quality.

The People Behind the Performance

Technology plays a major role in CCC efficiency, but the human factor remains critical. PerformRx invests heavily in recruitment, onboarding, and continuous training to ensure representatives have both the technical knowledge and the soft skills needed to engage effectively with members. The training program is comprehensive, extending well beyond basic phone etiquette to create true subject matter experts.

Training covers:

• Pharmacy and clinical knowledge: Understanding formulary structures, drug tiers, and benefit design is non-negotiable. Representatives are trained to answer questions and explain complex clinical topics clearly and simply.
• Regulatory compliance: Meeting CMS, HIPAA, and state-level requirements is essential in every interaction. Training includes rigorous modules on privacy, data security, and accurate documentation, protecting both the member and the client plan.
• Member empathy and communication skills: Ensuring every call is handled with professionalism, patience, and cultural sensitivity. This soft skills training is key to de-escalating difficult situations and turning a frustrating call into a positive experience. Representatives learn to listen actively, show genuine care, and provide a personalized experience that goes beyond a script.

These investments pay off in higher accuracy, improved member satisfaction, and a stronger brand reputation for client plans. The representatives are empowered to handle a wide range of issues on their own, which builds confidence and further increases FCR rates.

Scaling Without Compromising Quality

One of the hallmarks of the PerformRx CCC is its ability to scale services without sacrificing quality. This is particularly critical for health plans navigating enrollment surges, seasonal spikes, or rapid membership growth. The CCC’s flexible model allows it to adapt to fluctuating demand while maintaining its high standards.

The CCC leverages:

• Workforce forecasting tools to predict call volumes and adjust staffing in real time. This ensures that the right number of skilled representatives are available precisely when they are needed most.
• Cloud-based telephony that supports remote operations and disaster recovery scenarios. This technical resilience ensures uninterrupted service, regardless of external challenges.
• Integrated CRM systems that centralize member history, enabling faster, more personalized support. With a 360-degree view of a member’s interactions, representatives can bypass repetitive questions and address the core issue more efficiently.

These capabilities allow PerformRx to maintain service excellence across diverse client populations, from small regional plans to large multi-state organizations.

Beyond the Call: Proactive Member Engagement

While reactive service is essential, the CCC also plays a proactive role in supporting member health and satisfaction. This includes targeted outreach initiatives that can improve health outcomes and contribute to plan quality scores.

Proactive outreach includes:

• Outreach to remind members about medication refills or preventive services, addressing common barriers to adherence.
• Educating members on cost-effective medication alternatives, which helps them save money and increases their engagement with their benefits.
• Coordinating with clinical teams to close care gaps identified during calls. For example, a representative might identify a member who has not had a recent health screening and seamlessly connect them to a clinical team member who can help.

These initiatives not only improve member outcomes but also contribute to higher quality scores for client plans. By moving beyond a reactive stance, the CCC becomes a vital partner in member health management.

Continuous Improvement: A Data-Driven Approach

Performance measurement is a core discipline for the CCC. Metrics such as average handle time, FCR, and service level are tracked daily, with monthly trend analysis to identify improvement opportunities. This data-driven culture allows for constant refinement of processes and training programs.

Using call analytics, PerformRx can pinpoint recurring issues, such as benefit misunderstandings or formulary questions, and work with plan partners to address them upstream, reducing future call volume and improving member clarity. This approach moves beyond simply managing calls to strategically improving the member experience at its source.

The Business Impact for Plans and Consultants

For health plans and consultants, selecting a PBM with a high-performing call center is not a “nice-to-have”; it’s a strategic advantage. An efficient, member-focused CCC can:

• Reduce administrative burden on plan staff. By handling a higher percentage of member inquiries with high FCR, the PBM’s call center frees up internal plan resources.
• Improve Star Ratings through better member satisfaction scores. The seamless and professional support from a top-tier call center directly impacts key quality metrics, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores.
• Lower overall costs through higher FCR and reduced repeat calls. Fewer calls per member issue mean lower operational expenses and a more efficient allocation of resources.
• Strengthen member trust and plan loyalty. Exceptional service creates a positive feedback loop, leading to higher member satisfaction, improved retention, and a more competitive advantage in the marketplace.

In an era where health care consumers expect service on par with the best retail experiences, call center excellence can be a defining factor in plan competitiveness. An effective call center is a strategic asset, driving improved health outcomes, ensuring compliance, and boosting overall plan performance.

Partner with PerformRx for Unmatched Member Support

A high-functioning call center delivers an exceptional experience that improves health outcomes, supports compliance, and enhances plan performance. PerformRx’s Customer Care Center consistently exceeds CMS standards and national benchmarks, providing our clients with the service quality their members deserve.

Looking for a PBM partner delivers operational excellence and member satisfaction? Contact us at info@performrx.com to explore how our solutions can help your plan thrive.

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References

1. Centers for Medicare & Medicaid Services. Medicare Part D Call Center Requirements. https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/downloads/PartDCallCtrRequirements.pdf
2. Physicians Angels. Healthcare Call Center Statistics to Know. https://physiciansangels.com/learning-center/healthcare-call-center-statistics-to-know/
3. SQM Group. Call Center First Call Resolution (FCR) Benchmarking Report. https://www.sqmgroup.com/resources/library/blog/call-center-fcr-benchmark-2024-results-by-industry