October 10, 2024
Your organization has just completed a successful Pharmacy Benefit Manager (PBM) Request for Proposal (RFP) and decided to switch PBMs. The next critical step is implementing the new PBM services, which involves transitioning from the previous PBM. This process can seem daunting to plan sponsors, as concerns about ensuring a smooth transition and minimizing member disruption are valid. In fact, these concerns often deter organizations from switching PBMs, even when significant cost savings are possible.
However, the implementation process does not have to be stressful. With the right support from your pharmacy benefit consultant, this transition can bring many advantages. Holding PBMs to a higher standard ensures that the experience benefits both the plan sponsor and its members. In this overview, we will highlight key considerations to help plan sponsors ensure a seamless transition to a new PBM.
Implementation Preplanning
For smaller groups, implementation typically takes 120 days, while larger entities may need 9-12 months. PBM implementation is a complex process with many components, so it is essential to develop a clear strategy and maintain open communication with the PBM’s implementation team.
Consistent communication with the new PBM is crucial for successful implementation. While plan sponsors may have different levels of involvement, your pharmacy benefit consultant should meet frequently with the PBM and other vendors. Sponsors should also determine their role in the process and designate the individuals responsible for overseeing it.
Throughout the implementation, plan sponsors will need to sign several documents, such as Business Associate Agreements (BAA), Pharmacy Services Agreements (PSA), and benefit design documents. To avoid delays, designate a specific individual to manage document review, approval, and signing.
Key Decisions
Plan Design
One of the most critical elements of the implementation is ensuring the PBM incorporates the correct benefit design. This includes setting deductibles and out-of-pocket maximum accumulators correctly, whether based on the plan year or calendar year. It is also important to verify that copayments and coinsurance are properly aligned with drug types and supply durations.
Benefit Build
Make sure the appropriate drug classes are included or excluded according to the plan design. Sometimes, the PBM’s standard criteria may not match the plan’s current design. Having a clinical pharmacist, like those at Innovative Rx Strategies, ensures that all PBM documents are correctly interpreted with the plan’s intent in mind.
PBM Program Assessment
Plan sponsors should ensure accurate enrollment in programs like patient assistance and copay assistance programs, or integration with third-party vendors. While PBMs often highlight their programs’ benefits, a knowledgeable consultant is crucial to evaluate whether they align with the sponsor’s goals and whether the fees are justified. Programs can be costly, and some may lead to misaligned incentives, so careful consideration is necessary.
Data Transfer and Reporting
Accurate and timely transfer of data from the previous PBM to the new one is essential. This includes claims data, open prior authorization files, and refill transfer files. Some PBMs charge fees for data transfers, so it is important to assess whether the cost is worth it or if alternatives are available. Occasionally, new PBMs may offer credits that can offset these costs.
Additionally, during the RFP process, confirm that the new PBM has existing connections with your medical carrier to facilitate the transfer of accumulator and eligibility data. If these connections are not established, it could delay implementation. If the sponsor uses internal analytical platforms, ensure that data feeds are correctly set up during the implementation period.
Managing Disruption
Member disruption is often the biggest concern during a PBM transition. While some disruption is inevitable, proactive planning can minimize it. By analyzing potential disruptions and communicating changes to members in advance, sponsors can help members adjust smoothly. Pharmacists experienced in interpreting disruption reports and assessing actual member impact are invaluable during this phase.
Member Communication
When PBM services change, the new PBM will notify members through letters and phone calls, covering topics such as prescription transfers, mail-order pharmacy enrollment, member portal access, and potential changes in drug coverage. While these communications are routine, our team often uncovers errors or issues in templated materials that could confuse or mislead members. Reviewing these materials ensures clear, accurate messaging.
Quality Control
One of the most important steps in any implementation is ensuring that all decisions and instructions are accurately reflected in the final product. With so many teams involved, mistakes can happen. Once the PBM has integrated the benefit design, it is critical to test the benefit build to confirm that claims are processed according to plan specifications before going live. PBMs typically use test environments for this, but at Innovative Rx Strategies, we go further by requiring multiple unique test scenarios for our clients. This added layer of quality control ensures accuracy from day one.
Post-Launch Support
The implementation process does not end when the plan goes live. After the launch, our team continues to meet regularly with the PBM for weeks or even months to ensure claims are processed correctly and to address any issues promptly.
At Innovative Rx Strategies, we know the PBM implementation process can be complex and overwhelming. But plan sponsors do not have to navigate it alone. With our team of experienced clinical pharmacists and seasoned account executives, we provide expert support and advocacy throughout every step of the process to ensure a smooth transition for our clients and their members.
