I live in the USA and work for a US company. My employer issued health insurance switched its PBM to a new company at the beginning of the year. It has been hell working with them to get prior authorizations. I have called them so many times and sat for hours on the phone with them.
During these calls I noticed that they seem to be in a call center and their coworkers in the background aren't speaking English, just Hindi (my significant other also speaks Hindi so I can make out some of the words). Everyone I spoke with at the insurance company seems to be from South Asia (based on their name and accent). Even when one of the representatives called over his supervisor, he explained the situation to him in Hindi.
I know if we're just going off of my judgement during these calls then one could still consider it a baseless suspicion. But even so I can't help but wonder, would it be legal for a PBM to outsource their work to another country? I mean, these are my medications we're talking about. My name, my address, my diagnosis, etc. Even if it's just the health insurance, I still wouldn't be comfortable with this being processed in a different country.