Implementing a New PBM: Proven Strategies for Success

Once a new pharmacy benefit manager (PBM) has been selected through the RFP process, successful implementation becomes the top priority. A smooth transition hinges on asking the right questions and proactively managing key details. Engaging a pharmacy benefits consultant at this stage can offer invaluable strategic guidance and insight—well beyond the scope of typical implementation checklists. An expert consultant brings essential oversight—identifying critical issues and supporting the HR team at whatever level of involvement they prefer. While implementing a new PBM is an essential step, successfully implementing plan changes requires the added quality control, guidance and expertise that only a consultant can provide.

To ensure a seamless pharmacy benefit management consulting implementation, consider these key steps:

1 – Discovery and Assessment Planning

• Establish clear goals and objectives. Determine whether your objective is to closely mirror your current plan design or introduce changes. Remember, exact duplication isn’t possible because each PBM maintains its own formulary.
• Involve key stakeholders early. Identify the role internal departments, such as IT, communications, legal and finance, will play in implementation. Don’t overlook external partners, including those who support eligibility, accumulators and member service.
• Assess current challenges and successes. Determine what has worked well and where the plan can be improved—not just cost management, but across the broader member experience and the plan as a whole.

2 – Kickoff Meeting

• Lay the groundwork for implementation by introducing key participants, along with their roles and responsibilities. While your current PBM won’t be part of these meetings, they will still play a critical role in supporting the transition to your new PBM.
• Request detailed implementation materials from your new PBM, including specific requirements and timelines.
• Align on future meeting goals and objectives to ensure each session is productive and keeps the implementation on track.
• Initiate all legal and data-sharing agreements and ensure they’re fully signed. Unsigned agreements can stall the entire implementation timeline.
• Define and establish implementation performance guarantees to hold all parties accountable.

3 – Determine Preestablished Timelines to Hit Go-Live Date

• Align with internal teams and external partners to coordinate key deliverables.
• Establish clear timelines and deadlines for all stakeholders, accounting for leadership approvals and any required financial system setup.
• Develop a distribution schedule for member-facing materials to ensure timely and accurate communication.
• Consider claim migration, eligibility setup and utilization data, including adequate testing and validation time.

4 – Document Collection

• Request all necessary documentation from the current PBM.
• Collect relevant plan materials, including:
  • Current plan designs and structure, Summary of Benefits and Coverage (SBPs), change orders and documentation related to clinical programs, such as formulary and Utilization Management (UM) programs that are in place.

5 – Review existing plan design and consider changes

While many plan sponsors want to mirror their existing plan and coverage, it’s wise to work with a consultant to reassess key elements like clinical programs and coverage. The prescription drug landscape is constantly evolving, with new entrants to the market and new indications that could increase a plan’s financial exposure. It’s important to ask:

• Are our UM programs still appropriate or do they need updating?
• Does the current drug coverage still meet the needs of our members?
• Is our pharmacy network still meeting the needs of our members?
• What are the potential financial implications and level of member disruption of the possible changes?

Once decisions are made, be sure to update your SBP.

6 – Conduct a Pre-Implementation Audit

• Conduct testing of all variables of the benefit design to confirm claims are processing correctly before going live.
• Review and confirm that UM protocols are appropriate and align with clinical goals and member needs.

7 – Educate Members

• Evaluate and test mobile and digital tools available to both members and you as a plan sponsor, to ensure functionality before going live.
• Create a comprehensive communication strategy to educate members about upcoming changes, repeating key messages to reinforce understanding.
• Provide training for internal teams and external partners to ensure consistent and accurate support across all touchpoints.
• Ensure both current and new PBM member services teams are aware of and educated on changes.
• Plan for the pre-go-live support gap. Most PBM systems will be unable to assist members until the go-live date, so clarify how member inquiries will be handled during this transitional period.

8 – Conduct Testing

• Perform integration and data sharing across all vendor partners.
• Conduct a comprehensive benefit test, both before and after the go-live date, to verify that accurate claims are being processed as expected.
• Validate all pricing elements to ensure alignment with contractual terms and expected outcomes.

9 – Post Go-Live Audit

• Track claims activity across all benefit tiers to confirm accurate processing and identify any issues early.
• Monitor customer service calls to uncover trends, address gaps and identify opportunities for additional member education.

10 – Ongoing Management

Equally critical as implementation is ongoing oversight to ensure long-term success.

• • Establish a framework for continuous monitoring, including:
    • Trend and financial performance
    • Implementation guarantees

Conclusion

Ensuring a smooth implementation is critical when transitioning to a new PBM, as it directly impacts member experience, cost management and overall plan performance. Equally important is the successful execution of any plan design changes. A pharmacy benefits consultant brings the expertise needed to align the PBM’s contract and implementation[LH1]  process with both the original bid and your plan’s intent. During this time of change, they provide expertise and insights into critical issues, supporting the HR team so they can choose their preferred level of involvement in the process. With a consultant’s guidance, the transition becomes more seamless—minimizing member disruption, maintaining compliance and providing clear communication every step of the way.