How PBMs are tackling behavioral health

The COVID-19 pandemic exposed the cracks in America’s mental and behavioral healthcare system. At the height of the COVID-19 pandemic, depression and anxiety worldwide had increased by 25%, according to the World Health Organization, and 90% of U.S. adults believed the country was facing a mental health crisis, according to a KFF/CNN survey.

During that time, however, people had trouble finding and accessing affordable care. During COVID-19, many mental health providers retired, stopped accepting health insurance, or were not yet set up to deliver telehealth services. Since then, health insurance companies have made efforts to expand their networks and provided telehealth offerings for behavioral health.

Still, there has been little measurable progress in reducing rates of mental illness, and 23.4% of U.S. adults, or about 60 million people, experienced a mental illness in the past year. Another 5.6% met criteria for serious mental illness, and 17.7% of adults had a substance use disorder in 2024, according to data from a report published last year by Mental Health America, an organization dedicated to promoting mental health, advancing prevention, and driving policy innovation.

“The national rates of mental illness and serious mental illness among adults have not changed significantly since COVID,” Pierluigi Mancini, Ph.D., interim president and CEO of Mental Health America, said in a recent interview. “Youth data showed a slight improvement, including a 1% to 2% decrease in both major depressive episodes and suicidal ideation. It’s very clear young people are still struggling.”

More people are seeking care for behavioral health, but access is still an issue for many, Mancini said. “We have access problems from private insurance and from public insurance. There is also tremendous disparity in what’s covered. Even though we passed parity laws 25 years ago, we still don’t have parity in mental health and substance use disorder that is on par with general physical health coverage.”

For example, Mancini said limiting the number of sessions is common for mental health and substance abuse disorders. Other barriers to accessing care include transportation, childcare, lack of providers in rural areas, or lack of broadband services for telehealth.

At the same time, costs are increasing. Behavioral health utilization has skyrocketed by 62% since 2018, driven by patients staying in care longer, according to a new report from PwC’s U.S. PwC’s health researchers surveyed and interviewed actuaries at 27 U.S. health plans to produce an estimate of medical cost trends for 2027. The plans surveyed and interviewed cover more than 103 million employer-sponsored members and 8 million individual Affordable Care Act (ACA) marketplace members.

Employers understand that a lack of accessible and affordable mental healthcare has a long-ranging impact. In a new survey, conducted by Lyra Health and released in May 2026, benefit officials said that a decline in employee performance is linked to mental health challenges. More than one in four employees report that their mental health has declined over the past year. Workers cite mounting pressures including burnout, financial stress, caregiving responsibilities, job insecurity, and anxiety around artificial intelligence.

In this survey, 69% of benefits leaders say these challenges significantly reduced employee performance this year, and more than half report an increase in mental health-related leave or disability.

PBM mental health offerings

In an effort to lower overall costs and assist with medication compliance, some pharmacy benefit managers (PBMs) have added or upgraded programs that help plans address compliance and identify patients who may need additional support. Managed Healthcare Executive has conducted an informal survey of PBMs to determine what type of programs PBMs offer to assist their clients with behavioral health claims. (See table below.)

A common theme among those PBMs that offer these programs is the use of electronic tools to identify patients who may need additional support for mental and behavioral health or to identify those at risk for misuse of opioid therapies. These tools screen for patients who may be taking multiple medications or who need support from either a pharmacist or a physician to take medications as prescribed.

For example, Optum Rx has several programs, including Meds on Track (which helps to address medication adherence) and Personalized Rx Counselor (which identifies members who may be at risk for an adverse drug event). These programs use predictive algorithms, including AI, to help identify patients at risk, David Beshara, RPh, senior vice president, clinical engagement, Optum Rx, said in an interview.

“The AI module may say that a patient might become nonadherent; for example, it could be a patient new to antidepressant therapy,” he said. “Then we make a preemptive outreach to that patient to talk to them about what they need to remain compliant with their medications.”

But, he said, being a clinical-first organization is what ensures positive outcomes. The Meds on Track, for example, has resulted in 48% of nonadherent patients having achieved proportion of days covered at or above 80% after six months, which resulted in $26 per intervened member per month total cost savings.

Pharmacist outreach

Prime Therapeutics offers a behavioral health program, Whole Health Rx, that uses pharmacy claims data and proprietary clinical algorithms to flag specific concerns within behavioral health and opioid management. Prime pharmacists work with prescribing physicians to address polypharmacy, duplicate therapies, and high-risk drug combinations such as opioids prescribed alongside benzodiazepines. Rather than issuing one-time alerts, Prime pharmacists work to build ongoing relationships with prescribing physicians.

The program does not engage patients directly. Instead, it is designed to provide clinical support and resources to improve prescribing decisions and, where needed, tools to help counter misinformation patients may encounter online or through social media.

“Our intention is to take a more holistic approach,” Sagar Makanji, Pharm.D., vice president of Clinical Strategy & Programs at Prime, said in an interview. “The mental health or behavioral health component is more embedded within the product as a part of an overall approach. Even a program that’s focused on cardiovascular disease or diabetes, there’s always a mental health component embedded in there.”

For Whole Health Rx, Makanji cited a 60% overall reduction in identified care gaps among participating populations, including a 6% drop in members prescribed multiple antipsychotics simultaneously. In one case, the program generated nearly $2 million in annual pharmacy savings through deprescribing. Importantly, he stressed that savings are a secondary metric.

Whole Health Rx is an elective add-on for health plan clients and carries additional cost, though Makanji said program savings often offset that expense. Adoption has been highest among Medicaid plans, which tend to manage populations with complex behavioral and physical health needs.

Opioid management

In 2024, 2.8% of people over the age of 12 (or 8 million people) misused prescription pain relievers, including opioids; this number didn’t change between 2021 and 2024, according to a report released last year from the Abuse and Mental Health Services Administration. This survey found that patients most often said relieving physical pain was the reason for higher than prescribed doses. But 9.1% said they wanted to get high, and 7.5% said they wanted to relieve tension.

Although PBMs such as Judi Health | Capital Rx generally see opioids being used for short-term pain such as after surgical procedures, there is concern about the possibility of long-term use leading to addiction, said Nash Albadarin, Pharm.D., associate director, clinical programs business development, at Judi Health | Capital Rx, in an interview.

“We don’t want patients to take them for an extended period of time to minimize that risk for developing an addiction,” he said. “We’re not restricting use for those members that have chronic pain and chronic conditions that need treatment, such as those in hospice, cancer or sickle cell.”

Judi Health: Capital Rx’s opioid management program called Rx Ally aims to reduce member exposure to opioids and help mitigate adverse events. Rx Ally was launched in 2020 and expanded in 2024 to provide a higher-touch intervention. The program is integrated with the PBM’s adjudication platform, Judi, and not a standalone solution.

“We’ve designed it to reduce unnecessary opioid exposure and prevent adverse events through a combination of like automated safeguards and proactive clinical engagement, and we’re doing this in a multi-layered approach,” Albadarin said. “We leverage drug utilization review (DUR) to identify members that are at high risk. It’s been a program focused around combining the technological aspects of Judi with clinical oversight and human intervention. It’s a multi-pronged approach into how we manage opioid use and substance use disorders.”

For patients requiring a higher touch, both members and prescribers receive in-person and/or telephone outreach through a nationwide network of retail pharmacists. Pharmacists provide naloxone education and distribution to at-risk members. Naloxone reverses the effects of opioids and is used with people who have overdosed on opioids.

Additionally, the PBM conducts clinical medication reviews and assessments for patients using chronic opioid therapy or opioid use above established safety limits. Pharmacists address patients who are currently taking opioids and benzodiazepines or more than one short-acting or long-acting opioid.

Albadarin said about half of the PBM’s clients have adopted the Rx Ally program. Members enrolled in Rx Ally had a short-acting opioid day supply of 14.3 days fewer compared with members without Rx Ally. The number of members with daily morphine milligram equivalents (MME) ≥90 decreased by 11% over a 6-month period. MME is a standard measurement used in pain management to compare the relative potency of opioid medications. The average opioid day supply for opioid-naïve members dropped by 37% over a 12-month period.

An important part of the program is limiting the number of days patients are prescribed opioids when first given the prescription, Lauren Carroll, Pharm.D., BCACP, senior clinical programs manager Judi Health | Capital Rx, said in an interview. “By limiting the amount of opioids that the patients get initially, it can reduce the chance for dependence, abuse, and misuse, and oftentimes members have the same kind of clinical outcomes.”