The Essential Steps to a Successful PBM Transition

Phase One: Initiating Your PBM Transition 

The decisions you make at the beginning of your transition can determine the success of your entire PBM journey. The initial stage is all about getting key alignment information from your potential PBM partner to prevent surprises and miscommunications later on.

Key areas of alignment that you need to discuss with a potential pharmacy benefits manager on include:

• Communication & Support SLAs: Communication is a crucial part of your success with a new PBM. Spend early stages of your exploration determining their communication style, cadence, and SLAs—and if they suit your needs. Also, dig into the structure of their client support organization to understand who will be helping you along your journey. Ask if you'll have consistent support personnel assigned throughout the entire process. Finally, get a detailed understanding of the different kinds of meetings/ check-ins you’ll have during your implementation so you can assemble an internal, cross-functional team to make the transition a success (e.g., Human Resources, IT, and Legal stakeholders).

• Integrations: Before signing any contracts, it’s important to understand any technical components to your PBM transition and ensure your new pharmacy benefits partner is in alignment with your tech stack. Determine what their approach to technical integrations with other benefit vendors (like TPAs or data partners) is and clarify if these integrations happen at the same time as benefit implementation—or if they need to be completed beforehand. 

Phase Two: Planning with Your PBM Partner

Once the initial groundwork is laid, you can begin planning your transition. This phase often happens concurrently with contracting and other paperwork. By the end of this stage, you should have a solid transition plan and timeline in place with your account manager.

Before you finalize any contract with a new PBM, be sure to get clarification on:

• Timeline: Make sure you’re fully aligned with your PBM partner on timeline and order of operations for the implementation process. For example, nail down if contracting and implementation can run in parallel to save time, or if a contract needs to be 100% executed to move forward.

• Historical Data & Files: Get an exhaustive list of all the information your new pharmacy benefits partner could need as early as possible—especially considering your previous PBM may not be super forthcoming with information. It’s always a good start to pass along historical claims data, open refill transfer files (ORTFs), member census files, and prior authorization (PA) files.

• Benefit Design: Most crucially before signing a contract, verify that the terms your PBM is presenting 100% aligns with your goals—and if there’s flexibility in the benefits design structure for collaboration. Willingness to work with your team and provide flexibility where needed is a sign you’ve found a true partnership.

Phase Three: Implementing Your New PBM

Implementation is the core phase of your PBM transition—and it’s the most demanding. Your account manager should work with you to iron out plan details, align on goals, and set up tactics to maximize cost savings while minimizing member disruption. This is also the stage to test to ensure everything is in working order and there are no technical issues.

Your cross-functional team members will likely be heavily involved in this stage and will want to know about:

• Process: Discover how you’ll be getting insights into clinical data and plan performance to help guide benefits design decisions. You’ll also need to verify exactly how integrations and external vendor connections are run with your technical team.

• Testing: Be sure to run tests before going live to triple check everything is in working order.

• Member Support: Ask any and all questions about your members’ experience and flesh out any support you’ll need to make their transition smooth. This could include building tailored communications, available educational materials and self-serve tools—but an exceptional PBM partner will have all these materials for you! Be sure to get clear answers on terms for grandfathering and how specialty drugs/ other sensitive situations will be handled during the transition. 

Phase Four: A Successful Partnership Go-Live & Beyond

After all requirements are captured, built, and tested, it's time to set your program live. This stage involves a smooth hand-off from the implementation team to your regular account manager, and ongoing communication to ensure 100% visibility into performance.

Before you switch your new PBM “on”, be sure you have clarity on:

• Performance Monitoring: Your new PBM partner should proactively monitor claims and escalate issues before they affect members. You should also know their SLA (Service Level Agreement) for issue resolution and what their process is for handling unhonored prior authorizations.

• Support Metrics: A reliable PBM should be transparent about their member support metrics. Ask for data on their average speed to answer, call volumes, and call abandonment rates to understand their commitment to member service. 

• Ongoing Partnership: Establish the standard cadence for ongoing client communication, such as quarterly business reviews and reporting. The transition should include a clean handoff from the implementation manager to your long-term account manager. Ideally, the account manager will be involved throughout the entire process!

Download the Primer and Watch the Webinar

A successful PBM transition requires proactive communication, transparency, and collaboration. Does your PBM offer all of that? If not, it may be time to make the switch to a truly modern PBM. 

Watch the Full Disclosure webinar for a deeper dive into these key stages and insights from our experts. And, to help you along the way, download the PBM Transition Primer—a clear, actionable guide for your next steps.