A formulary update looks routine on paper. A tier gets adjusted, a biosimilar gets preferred, a drug loses coverage. Then the phones light up. Pharmacy benefit manager call center outsourcing exists precisely for this moment, when a policy memo turns into thousands of confused, anxious member calls within days. For PBM leaders chasing organic growth and member retention, understanding why these spikes happen, and how to absorb them without breaking service levels, has become a competitive necessity rather than a nice-to-have.
Why Formulary Change Call Volume Spikes Without Warning
Every formulary revision touches real people mid-prescription. A member who has taken the same maintenance drug for years suddenly learns it costs more, or worse, is not covered at all. Naturally, they call. Industry data shows how often this happens: in 2022 alone, 1,156 drugs had their formulary status changed, according to the Center for Medicare Advocacy, cited by Medicare Solutions and Retirement. Meanwhile, a 2024 Medicare Rights Center survey found that 62 percent of beneficiaries did not understand how to appeal a formulary decision. That confusion translates directly into hold-time chaos.
Formulary change call volume rarely follows a gentle curve. It behaves more like a cliff. One documented case makes this vivid. When CVS Caremark removed brand-name Humira from its main commercial formulary in April 2024 and pushed members toward a preferred biosimilar, the shift triggered a dramatic wave of plan switching. Roughly 13 percent of affected patients eventually switched back to the original drug, with nearly 40 percent of those reversals happening within the first 30 days, according to DrugPatentWatch. Every one of those transitions generated calls: coverage questions, appeal requests, and pharmacist callbacks. A single national decision rippled into member service queues everywhere.
The Real Cost of an Unprepared PBM Member Services Team
Internal member services teams are usually staffed for average daily volume, not for cliffs. Consequently, when formulary letters land in mailboxes, hold times stretch, abandonment rates climb, and frustrated members turn to social media or state regulators instead of resolution. Dr. Robert E. Kalb, of Buffalo Medical Group in New York, captured the underlying tension well: “It’s a very difficult issue, when a prescribed medication is not on the formulary or there are significant step edits,” he told the American Academy of Dermatology’s Dermatology World. That difficulty does not stay contained to the physician’s office. It spills straight into the call queue, where under-resourced agents are left explaining decisions they had no part in making.
There is a financial dimension here too, one that boards notice quickly. Unanswered calls do not just frustrate members; they represent lost retention and lost referral value. As one healthcare operations executive put it, reported by SkyCom, “Every unanswered call is not just a missed interaction. It is a missed opportunity to retain revenue.” For a PBM competing on member satisfaction scores and Star Ratings, that missed opportunity compounds fast.
How Pharmacy Benefit Manager Call Center Outsourcing Solves the Spike Problem
This is where outsourcing earns its keep. Rather than hiring and training permanent staff for volume that appears three or four times a year, PBMs can lean on a partner that already maintains a trained, certified bench. Healthcare organizations working with specialized partners saw a 40 to 50 percent increase in inbound inquiries during peak periods, and still held service levels, according to Ameridial’s own healthcare call center outsourcing guide. Similarly, open enrollment call volumes for mid-sized administrators can spike more than 200 percent, a pattern documented in Ameridial’s TPA call center outsourcing guide. Formulary-driven spikes follow that same shape, arriving suddenly and demanding immediate scale.
Pharmacy benefit manager call center outsourcing works because ramp time shrinks dramatically. Agents can be added within hours, not weeks, once a partner already has HIPAA-compliant infrastructure, formulary-specific scripting, and escalation protocols in place. Consequently, PBMs avoid the two worst outcomes at once: overstaffing during quiet months and understaffing when a P&T committee decision hits mailboxes. This flexibility, not simple cost reduction, is why outsourcing has become a growth lever rather than a budget line item.
Inside a PBM Member Services BPO: What Good Actually Looks Like
Not every contact center can do this well. A capable PBM member services BPO blends healthcare-specific training with genuine empathy, because members calling about a denied medication are often scared, not just annoyed. Agents need fluency in tier structures, step therapy rules, and exception processes before they ever answer a live call. They also need systems that talk directly to claims and eligibility platforms, so a member never has to repeat their story three times.
Quality shows up in the numbers a partner is willing to share. Documented healthcare outsourcing results include abandonment rates held under 3 percent, compared with an 18 percent rate one client experienced before switching providers, against an industry benchmark closer to 5 percent. Those figures matter more during a formulary spike than at any other time of year, because that is precisely when service quality is hardest to protect.
Real-World Proof: The Humira Formulary Shake-Up
The Humira biosimilar transition deserves a second look, because it shows the whole problem in miniature. A single formulary decision by one PBM reshaped prescribing patterns for hundreds of thousands of patients almost overnight. Some members adapted smoothly. Others called repeatedly, confused about copay differences, pharmacy availability, and whether their doctor even knew about the switch. A well-prepared PBM member services BPO turns that chaos into a manageable, even reassuring, experience. Members get clear answers about their new copay, their pharmacy options, and their appeal rights, all without a 45-minute hold. That is the difference between a formulary change that damages trust and one that barely registers as an inconvenience.
Choosing the Right PBM Member Services BPO Partner
PBM leaders evaluating a partner should look past the marketing deck and ask harder questions. How fast can the vendor scale from ten agents to a hundred during a formulary rollout? What HIPAA, SOC 2, and PCI certifications back their operation? Do their agents train specifically on formulary language, or only on generic healthcare scripts? A partner who cannot answer these clearly, with data rather than reassurance, is not ready for a real spike. And to be fair, nobody wants to discover a vendor’s scaling limits for the first time while their own hold-music playlist becomes a member’s whole afternoon.
The Bottom Line for PBM and Health Plan Leaders
Formulary changes are not going away. If anything, tiering strategies, biosimilar substitutions, and rebate-driven adjustments are becoming more frequent as PBMs compete on cost containment. Formulary change call volume will keep arriving in unpredictable bursts, and members will keep expecting fast, accurate, human answers. Organizations that treat pharmacy benefit manager call center outsourcing as core infrastructure, not emergency overflow, protect both their Star Ratings and their reputation. Ultimately, the PBMs that scale member support intelligently are the ones that keep members enrolled, satisfied, and less likely to switch plans out of frustration alone.
Ready to stop dreading formulary rollout day? Ameridial builds healthcare-trained, HIPAA-compliant member support teams that scale within hours, not weeks, so your members get answers and your internal team gets their sanity back. Talk to Ameridial about building a PBM member services BPO strategy built for spikes, not just steady-state volume.
