simplify pharmacy benefits communication

How to Talk About Pharmacy Benefits Without Getting Lost in the Jargon

September 9, 2025

Key Takeaways

Focus on three core questions employees need answered: what medications are covered, how much they'll cost, and where prescriptions can be filled
Replace complex terminology with real-life examples and scenarios that show actual cost differences and savings opportunities
Use visual tools like infographics and quick-reference guides to improve comprehension—people retain 80% of what they see versus 20% of what they read
Provide year-round support through Q&A sessions, monthly tips, and accessible help channels rather than limiting education to open enrollment periods
Structure communications around cost, access, and convenience since these are the primary concerns for most employees using pharmacy benefits

A pharmacist giving advice to an older patients who is asking questions about their prescription

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Prescription medication usage affects a substantial portion of the American population: 60% of adults take at least one prescription drug, while 25% take four or more medications daily.

The widespread reliance on prescription medications contrasts sharply with public understanding of pharmacy benefits. Data shows 29% of Americans skip prescribed medications due to cost concerns. This disconnect becomes more significant when examining the scale of the pharmaceutical market—U.S. sales reached approximately $555 billion in 2021. Market concentration adds another layer of complexity, with three Pharmacy Benefit Managers (PBMs) controlling nearly 80% of prescription benefits nationwide.

Explaining pharmacy benefit manager functions or clarifying PBM terminology to employees often results in confusion rather than clarity. Technical language creates barriers that prevent teams from accessing benefits they fund through their premiums.

This guide addresses pharmacy benefits communication by translating complex industry concepts into practical language. The focus centers on information that drives better healthcare decisions rather than industry jargon that obscures understanding.

Why Pharmacy Benefits Feel So Confusing

The healthcare industry has developed a complex system built on technical terminology that creates barriers for most people outside the field. This complexity stems from both genuine industry intricacies and deliberate obfuscation of key information.

Common terms that trip people up

Pharmacy benefit terminology challenges even experienced HR professionals. Industry-standard terms like "formularies," "prior authorization," and "step therapy" create significant communication barriers for employees.

Formularies represent medication lists divided into coverage tiers, with some plans maintaining seven different cost-sharing levels. The distinction between "copayments," "coinsurance," and "deductibles" directly affects out-of-pocket costs but remains unclear to most plan members.

Additional terminology includes:

Spread Pricing: PBMs charge employers more than they reimburse pharmacies, retaining the difference
Rebates: Manufacturer payments to insurers or PBMs for formulary placement
Prior Authorization: Approval requirements before medication coverage begins
Step Therapy: Requirements to attempt lower-cost alternatives before accessing preferred medications

PBM contracts frequently use opaque language that obscures plan complexities from employers. Convoluted pricing structures and embedded fees make contract terms difficult to interpret, limiting employers' ability to assess true costs.

How jargon leads to poor decisions

Confusing benefit structures result in employees overpaying for medications, skipping prescribed treatments, or experiencing system frustration. These outcomes generate higher healthcare costs, reduced productivity, and increased stress for both employees and employers.

Market concentration compounds these communication challenges. Patients and physicians lack meaningful influence over PBM pricing and coverage decisions. The dominant market position of major PBMs enables them to structure benefits that maximize their profits rather than optimize patient outcomes.

PBMs negotiate manufacturer rebates contingent on excluding lower-cost competitors from formularies, assigning high cost-sharing tiers to competitive products, or implementing restrictive utilization management. These practices can prevent access to effective, lower-cost therapeutic alternatives for both patients and plan sponsors.

Data reveals the financial impact: the three largest PBMs generated approximately $1.40 billion from spread pricing on 51 generic specialty drugs over five years. Plan sponsors often believe they receive favorable pricing on certain medications while unknowingly overpaying for others.

Employees who cannot determine what medications are covered, associated costs, and pharmacy locations fail to optimize their benefit value.

Start with What Matters Most to People

Effective pharmacy benefits communication requires addressing the primary concerns of your audience rather than presenting technical specifications that create confusion.

Focus on cost, access, and convenience

Cost represents the primary barrier to prescription medication access. Data indicates 48% of Americans report medication prices have affected their ability to obtain necessary medicines at least once. Additionally, one in three Americans cannot afford their prescribed medications.

Financial stress affects more than two-thirds of employees, making cost considerations the dominant factor in benefit utilization decisions. Small cost reductions produce meaningful impact—$10 to $15 savings per medication can accumulate to $500-$600 annually through proper guidance toward lower-cost alternatives.

Two additional factors determine benefit utilization rates:

Access to medications: Employees require specific information about prescription filling locations and covered medication lists
Convenience: Complex benefit systems and lengthy pharmacy processes create utilization barriers

Modern workers expect pharmacy benefits to match the functionality of consumer applications they use regularly. Streamlined processes that eliminate friction improve medication adherence and employee satisfaction.

Communications should center on these three core areas. Rather than detailing formulary development processes, provide specific information about covered drugs, associated costs, and filling locations.

Use real-life examples to explain coverage

Concrete examples produce better comprehension than theoretical explanations. Cost comparison scenarios—such as $0 copay medications versus $50 out-of-pocket expenses—immediately demonstrate financial impact.

Prescription coverage explanations work effectively with tier-based examples:

Tier 1: Generic medications at $10
Tier 2: Preferred brand-name drugs at $30-50
Tier 3 and above: Non-preferred or specialty drugs at higher costs

Network discussions should include specific pharmacy options. Employees can access prescriptions at over 65,000 pharmacies nationwide, including major chains and independent local pharmacies. This information proves more valuable than PBM contracting process explanations.

Benefits communications should connect to daily experiences. Home delivery options save time for busy employees. Coverage option comparisons should show out-of-pocket cost variations for commonly prescribed medications within your organization. Persona-based examples clarify benefit applications: "Jane takes blood pressure medication. Our pharmacy benefit saves her $300 annually compared to out-of-pocket payments." These scenarios help employees understand benefits within their specific situations.

Pharmacy benefit communication effectiveness depends on answering four essential questions: What medications are covered? What are the costs? Where can prescriptions be filled? What savings opportunities exist? Addressing these concerns with clear examples enables better healthcare decisions without technical complexity.

Break Down the Basics Without the Buzzwords

Three essential questions determine pharmacy benefit utilization: medication coverage parameters, associated costs, and dispensing locations. These fundamentals require clear explanation without technical complexity.

What's covered and what's not

Pharmacy coverage operates through a formulary—the definitive list of covered medications under your plan . Formularies structure medications into tiers that establish both coverage levels and cost-sharing requirements.

Medication inclusion on this list determines coverage eligibility. Excluded medications typically lack coverage entirely. Exclusions occur when less expensive therapeutic alternatives exist or when clinical evidence doesn't support inclusion.

Formulary-listed medications may carry additional requirements:

Age-specific restrictions for certain drug categories
Prior authorization protocols requiring physician approval before coverage activation
Step therapy mandates that require trial of lower-cost alternatives first

Formularies undergo periodic updates throughout the plan year based on cost negotiations, clinical evidence, and market conditions. Regular verification of medication coverage status prevents unexpected benefit changes.

How much will it cost?

Out-of-pocket expenses depend on three primary cost determinants:

Tier placement affects medication pricing across coverage levels:

Tier 1: Generic medications at lowest cost-sharing
Tier 2: Preferred brand-name drugs with moderate costs
Tier 3: Non-preferred brand-name medications at higher cost-sharing
Tier 4+: Specialty drugs with maximum cost-sharing requirements

Cost-sharing structure varies by plan design:

Copays: Fixed dollar amounts per prescription (example: $10 for tier 1 medications)
Coinsurance: Percentage-based costs (such as 20% for specialty medications)
Deductibles: Annual amounts paid before coverage begins

Network pharmacy selection directly impacts costs. Out-of-network pharmacy use often requires full retail payment, with expenses potentially excluded from deductible calculations.

Price variations between pharmacies reach significant levels. Identical medications cost $4.50 at one location versus $140 at another pharmacy within the same geographic area.

Where can prescriptions be filled?

Prescription fulfillment occurs through multiple pharmacy channels:

Retail pharmacy networks: Optimal for immediate medication needs and short-term prescriptions. Network verification before prescription filling prevents unexpected cost exposure.
Mail-order pharmacy services: Designed for maintenance medications with regular refill requirements. These services provide 90-day supply discounts and direct-to-home delivery.
Specialty pharmacy providers: Required for complex, high-cost medications treating conditions such as multiple sclerosis or hemophilia. These facilities offer clinical support services and specialized medication management.

Pharmacy network composition changes during plan years based on contract negotiations and performance standards. Plan restrictions may limit pharmacy access based on negotiated pricing agreements. Regular network verification through insurance portals or mobile applications prevents billing surprises.

Simplify Communication with Visuals and Tools

Visual communication demonstrates measurably superior effectiveness for explaining pharmacy benefits. Research data indicates people retain 80% of what they see, compared to 20% retention for written content and 10% for auditory information. These retention rates make visual tools particularly valuable for pharmacy benefit education.

Use charts and infographics

Infographics convert complex data into accessible visual formats that serve as alternatives to dense text explanations. Pharmacy benefit communications benefit from three specific infographic types:

Statistical infographics: Display correlations, patterns, and trends through charts and graphs that text alone cannot effectively communicate
Comparison infographics: Facilitate understanding of differences between pharmacy plans or medication tier structures
Process infographics: Present information in sequential, logical patterns that clarify procedures

Engagement metrics support visual content effectiveness. Research shows tweets containing infographics had nearly double the engagement rate (10.97%) versus tweets linking to peer-reviewed articles (5.33%).

Create a quick-reference guide

Quick-reference guides function as educational tools that present essential information in formats designed for easy comprehension and retention. Effective guides contain four key components:

Coverage information including medications and exclusions
Cost explanations detailing copays and payment structures
Pharmacy location details for prescription fulfillment
Contact information for additional questions

Insurance providers frequently offer these resources. Anthem Blue Cross provides guides containing pharmacy benefit information, prescription ordering instructions, and supplementary resources.

Digital formats optimized for mobile access extend guide utility beyond traditional printed materials.

Offer a pharmacy benefits glossary

Pharmacy benefits glossaries define technical terminology using clear, accessible language. These reference tools remove barriers created by industry jargon that can prevent optimal benefit utilization.

Essential glossary terms include:

Formulary (covered medication lists)
Prior authorization (approval requirements)
Copay/coinsurance (payment structures)
Deductible (pre-coverage payment amounts)

Organizations like Premera offer detailed glossaries defining pharmacy-related terms from "allowed charges" through "out-of-pocket maximum”.

Visual tools and reference materials increase pharmacy benefit accessibility, resulting in improved comprehension and better healthcare decision-making.

Support Ongoing Understanding Year-Round

Pharmacy benefit education extends beyond open enrollment periods. Continuous support throughout the year enables employees to maximize their benefits and make informed medication decisions.

Host Q&A sessions or webinars

Educational webinars provide effective clarification of pharmacy benefit concepts. Organizations frequently offer regular live and on-demand sessions addressing critical topics including coordination of benefits, medication access, and transparency. These sessions establish clear learning objectives and tackle practical concerns including:

Pharmacy benefit manager roles and prescription drug benefit overviews
Essential contract terms requiring review and comprehension
Cost control strategies while maintaining optimal value

Quarterly continuing education webinars keep participants informed about current pharmacy topics and industry developments. Specialized training sessions address standards outlined in recent federal legislation, maintaining compliance with evolving regulations.

Send monthly benefit tips

Regular communication reinforces comprehension and promotes better benefit utilization. Effective monthly communications account for individual differences in experience, challenges, and health literacy levels.

Tailored communication approaches work optimally—certain employees require brief reminders while others need detailed explanations. Existing health literacy resources, including toolkits from healthcare research organizations, provide foundation materials that eliminate redundant development efforts.

Make it easy to ask questions anytime

Pharmacy care requires individualized approaches rather than standardized solutions. Multiple communication channels facilitate better understanding. Community pharmacists develop sustained, trusted relationships that enable ongoing dialogue.

Basic structural modifications eliminate information access barriers. Clear signage, readily identifiable pharmacists, and simplified language contribute to improved comprehension. This approach prioritizes patient-centered pharmacy information design over professional-oriented materials, employing familiar terminology rather than technical language.

Personalized attention combined with structural improvements creates environments where employees ask questions comfortably, resulting in improved healthcare decision-making.

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Conclusion

Pharmacy benefits communication requires precision rather than complexity. This analysis demonstrates how eliminating technical jargon improves employee understanding of prescription coverage. Direct communication about pharmacy benefits produces measurable outcomes: reduced costs, improved medication adherence, and decreased administrative friction.

The data supports focusing on three specific information requirements: medication coverage details, cost structures, and pharmacy network locations. Communication frameworks built around these elements make complex benefit structures accessible to employees regardless of their healthcare literacy levels.

Visual communication tools and reference materials demonstrate superior comprehension rates compared to text-based explanations. Structured education programs—including webinars, periodic updates, and accessible support systems—enable year-round benefit utilization rather than limiting engagement to enrollment periods.

Pharmacy benefit complexity reflects decades of industry development, requiring sustained communication efforts rather than single-point interventions. Plain language communication focused on employee priorities produces better healthcare decision-making outcomes while reducing confusion generated by industry terminology.

Effective pharmacy benefits communication extends beyond cost containment. Informed employees make evidence-based healthcare choices, report lower medication-related stress, and recognize employer investment in making complex systems accessible. Implementation of these communication protocols begins immediately, enabling teams to access their pharmacy benefits with increased competency and confidence.

References

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