Pharmacy benefit managers in Canada have undergone a significant transformation over the years, said Akhil Pandit Pautra, senior manager of clinical services, health claims administration and fraud, waste and abuse at Express Scripts Canada, during a session at Benefits Canada’s 2025 Face to Face Drug Plan Management Forum.
The role has evolved from the early days of managing paper-based pharmacy claims to becoming sophisticated, technology-driven organizations that hold a pivotal position in the country’s health-care system, he noted, greatly improving efficiency, privacy and sustainability in drug benefit management.
“Plan sponsors make key decisions about coverage and cost containment, while insurers may provide or outsource PBM services. Advisors act as trusted intermediaries and PBMs deliver the operational backbone.”
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PBMs are strategic partners, balancing the often competing needs of a variety of stakeholders, such as plan sponsors, insurers, advisors, pharmaceutical companies and pharmacies, said Pandit Pautra. By facilitating collaboration and transparency among all parties, PBMs foster trust and accountability, he added, noting these are essential for effective drug benefits management.
PBMs also offer a suite of services to help manage drug plan costs and improve patient outcomes. The core services include: point-of-sale adjudication, pharmacy network management, evidence-based formulary design, drug utilization reviews, patient adherence programs and data-driven coverage optimization.
In addition, he noted enhanced services like prior authorization management, fraud detection and clinical programs, product listing agreements and benchmarking reports can help plan sponsors optimize drug plan performance, ensure compliance and maintain cost-effectiveness in an evolving health-care landscape.
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PBMs can also leverage advanced analytics and [artificial intelligence] to address fraud, waste and abuse detection, said Pandit Pautra, noting they can use machine learning and pattern recognition to identify emerging fraud patterns, while enhancing plan sustainability and protecting member experience.
Looking forward, he suggested the promise of electronic prior authorization could reduce approval times from weeks to minutes and streamline access to medications and reduce administrative burdens.
Pandit Pautra recommended plan sponsors take a proactive approach to managing drug benefits by thoroughly understanding their contracts with all stakeholders, regularly benchmarking their plan’s performance and closely monitoring policy changes that could impact coverage or costs.
“It’s essential to protect the member experience, foster innovation through strategic partnerships and maintain strong governance to ensure that decisions support both financial sustainability and well-being of plan members.”
Read more coverage of the 2025 Face to Face Drug Plan Management Forum.