Implemented New PBM Member Experience Capabilities


For both contractual and strategic reasons, a healthcare insurance company needed to jointly build out a new Pharmacy Benefit Manager (PBM). The company was looking for integrated medical and pharmacy benefits for members including billions of dollars of pharmacy savings per year. From an overall service experience standpoint, there was a need to effectively manage and deliver the scope of program and project work that was directly owned by the Member Experience (ME) work stream or impacted the ME work stream. In a nutshell, Member Experience owns initiatives that directly interface with the member through call center associates.


The solution was unique in the fact that the company and its partner, had to jointly deliver changes to stand up to the capability for the new entity’s associates that would be able to service members who have pharmacy benefits. Projects were stood up across member experience (ME) to ensure member eligibility was accessible and accurate, member demographics and preferences could be updated, ID cards could be delivered, member portals stood up with self-service capabilities, associates could communicate with member via secure messages and chat, and clinical care triggers could be delivered securely, amongst others.

The uniqueness of the solution also extended to a hybrid project delivery methodology. The insurance company utilized an Agile/SAFe delivery model while the integration partner employed a traditional waterfall model. This led to a need for close coordination and expectation management in terms of project phasing and deliverables that were produced on either side.


The initiative is ongoing with continuing follow-on work. It has been viewed as a success because the insurance company was able to migrate groups of members early. Due to this success, the insurance company has begun to realize savings on the pharmacy side early while delivering value to customers and shareholders faster than initially expected. Due to this success with its own membership, the new entity will be able to compete for members in the PBM marketplace potentially delivering even more shareholder value going forward.