Collaboration in Action: What It Takes to Make a Smooth PBM Transition
No matter the industry, benefits leaders at organizations large and small know the importance of delivering for those they serve – the American workforce. They have long recognized that employee benefits play a huge role in an overall compensation package. On top of building a competitive compensation structure, self-insured employers governed under ERISA have a fiduciary duty to act in the best interest of their employees. When it comes to pharmacy benefits, that means choosing a PBM partner that works transparently – offering visibility into where money is flowing, who benefits financially at each supply chain touchpoint, and how the inner workings of pharmacy benefits impact the individual plan member.
An intensifying spotlight on the PBM industry from lawmakers, employer groups, and other stakeholders has resulted in more interest than ever in next-generation transparent PBM offerings. In fact, according to one employer survey more than 6 in 10 employers have either changed or are considering changing PBMs in the next one to three years. However, transitioning PBMs is no small feat. At AffirmedRx, our Implementation Team supports employers through a smooth PBM transition with flexibility, attention to detail, and thoughtful planning in partnership with benefits leaders. We’ve created an organizational structure built around delivering seamless pharmacy benefits transitions with five key phases.
Initiation
The initiation phase is where AffirmedRx organizes the foundational elements required for success. As soon as we win a partnership with a new client, our Sales team quickly relays all relevant and foundational information to the Implementation team – where are our goal lines? What target dates are most relevant to which teams? What unique information about the client was gathered during the RFP process? Stewards of AffirmedRx never work in silos.
Planning
AffirmedRx’s Implementation Team works closely with benefits leaders during the planning phase to fully build the plan’s pharmacy benefit requirements and is the longest and most crucial phase of implementation. Once the Implementation Team completes its handoff from Sales, it begins standing up the full framework that will support the transition from start to finish. This includes assigning resources, developing a detailed project plan aligned to the client’s go-live date, and preparing the internal and external kickoff materials that set expectations early.
During this phase, our team proactively reviews all documentation received during the RFP and intake processes. Rather than starting from a blank slate, AffirmedRx utilizes the client’s current benefit set up as the starting point to discuss and define what benefits will be. This is done in a clear and organized way focused on the plan member. Planning also involves early coordination with vendors including the TPA (Third Party Administrator) and consultants to obtain critical files and timelines, such as enrollment and claims history, enabling downstream teams especially Clinical to initiate disruption analyses, formulary transition planning, and other foundational activities without delay.
Build & Execution
During the Build & Execution phase, our cross-functional teams and third-party partners translate the finalized benefit requirements into a functioning benefit structure. This is where configuration, coding, and integration work begins. Rigorous quality assurance (QA) processes validate benefit logic in a test environment prior to user testing. Materials to be distributed to the new membership (e.g., welcome packets) are also developed during this phase.
Testing
Testing is where we validate that all stakeholder intent has been translated accurately into the pharmacy benefit system. An extensive suite of automated test cases, covering a litany of common claim scenarios help confirm expected results across plan designs, drug tiers, pharmacies, and co-pay structures. We then layer on targeted client-specific testing that takes into account any unique plan nuances or custom configurations. Our teams run real claim scenarios in the test environment using test member profiles to confirm that outcomes match the client’s approved requirements. Accuracy at this stage plays a key role in delivering a smooth PBM transition.
Go-Live & Steady State Transition
Go-live marks the moment when partnership with AffirmedRx becomes real for members. To support a seamless launch, AffirmedRx establishes a central “command center” – a highly coordinated, cross-functional, all-hands-on-deck environment focused on real-time claims monitoring, rapid issue resolution, and uninterrupted access to care. During these initial days, our clinical, file management, and claims processing business leaders work closely to triage claim rejections, validate messaging, and address any unexpected system behaviors. This period is intentionally high touch to safeguard members and give clients full confidence that their pharmacy benefits are functioning correctly from day one.
After the first few weeks, as claim patterns stabilize and outstanding issues are resolved, the implementation enters the steady state phase. This transition involves handoffs to our client success team who take over day-to-day support and strategic partnership. Our implementation team works to build a strong foundation for long-term success prior to handoff, resulting in what one client called “one of the smoothest implementations” they have undertaken.