PBM Integration

Enhancing Customer Experience Through Real Time Accumulator

Agile Health Technologies has worked extensively for various BCBS organizations. Our most recent success includes implementation of Prime Therapeutics at Blue Cross Blue Shield of Rhode Island
PBM in Healthcare – In order to stay competitive and offer the best possible experience to its members, every health plan chooses a PBM that meets their business objectives and consumer needs. Objectives such as discount and benefits, generic fill rate and transition to generics, speciality pharmacy, adaptive pricing, etc. are deciding factors in choosing the right PBM. A change in PBM also brings in business process changes and systems changes. At Agile Health Technologies Inc., we provide not only system integration and business solutions for PBM migration in Healthcare, but also continue to work with you to ensure the business objectives of the PBM migration are realized, benchmarked and socialized.

PBM in Healthcare – Agile Experience

Agile Health Technologies and its professionals have successfully completed PBM migrations such as migrating from WellPoint (now Express Script) to CVS Caremark, CVS Caremark to Catamaran/Optum Rx, and Optum Rx to Prime. We are experienced in both traditional batch integration and cutting edge, real time transactions.
  • Agile’s blended shore delivery model supplies an end-to-end solution for PBM integration
  • On-time and under budget meticulous planning and reusability analysis allows customers to lower the cost of implementation and     ownership

Our Best Practices

  • Migration frame work and reference architecture
  • Perfect blend of business and technical knowledge, as well as management
  • Efficient stakeholder engagement
  • Agile program management through business requirement prioritization
  • Go live through command center approach
  • Well-coordinated partner/UAT testing
  • Value-based post-implementation testing and support
  • ROI validation to enable the realization of implementation values

Agile PBM Integration

Agile Health Technologies provides complete end-to-end PBM Systems Integration in Healthcare through our integration framework, reference architecture, proven program management methodology, efficient stakeholder engagement, and structured testing. We understand the challenges of PBM implementation and utilize a successful process, tools, and techniques to help our customers in overcoming those hurdles. We go beyond the technical implementation, ensuring business needs and objectives are met. For example, adaptive pricing is a qualifying parameter for PBM. We work closely with both the business and PBM vendor to ensure the application of the right adaptive pricing rule based on enrollment. We make sure the correct LICS levels are applied by the PBM for Medicare, the right cost-sharing is used and appropriate shadow claims are processed.

PBM implementation involves appropriate stakeholder engagement and partner testing to ensure all plans from the Health Plan are mapped correctly at the PBM level, all pricing rules and benefits are applied accurately, and all rebate and healthy living programs are implemented at the PBM level as per the plan need. At Agile we bring in the perfect blend of business and technical knowledge to ensure these success factors.

PBM in Healthcare Analysis – After implementation, we analyze new PBM transactions and data to validate conformance to business objectives, modeling the path to ROI realization and any necessary corrective action plan.

Implementation Framework

Rules Engine: Agile technical framework defines the rules engine as the hub for all interfaces and transactional data. This becomes the central repository of all business rules such as a hybrid or aggregate plan for accumulator, carry over, or any plan specific business rules, etc.

Reference Architecture: An established reference architecture allows reusability of existing interfaces and extracts, establishing control and balance in every step. Performance, scalability, maintenance and operability are important criteria in the reference architecture.

Partner Engagement: The success of PBM implementation is dependent on effective partner engagement. Agile framework defines comprehensive and wise engagement at each phase to ensure all business objectives, requirements, joint testing and implementation/go live plans are met.

Agile Health Technologies Inc.’s PBM integration expertise and blended shore delivery model provide the most cost effective and high-quality implementation. If you would like to know more about our complete PBM integration framework, or our expertise and capabilities, please contact us at sales@agilehealthtech.com.

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