Pharmacy Benefit Migration Considerations
A Human-Centered Design Approach
The Goal
Over the course of several months, the health insurance organization empowered the Design Thinking team with two objectives. First, understand the migration journey of our commercial members and create an assessment of the impact to this change. Lastly, conduct research to intimately understand our members needs for their pharmacy benefits and imagine the future state.
The Plan
Subsequent to the ask, we developed a strategy that would naturally encompass those two phases of work. Phase One would concentrate on the possible immediate impacts to our commercial segment considering a migration completion date of 1Q 2022. The second part of the work or Phase Two would consider the future state experience (2023+) for all members (research is currently underway for the remainder of 2021).
For Phase One our impact assessment would examine key moments of abrasion to focus on communications for the MVP experience. We would then do a deeper dive and provide severity scores to help prioritize mitigation efforts. Supporting documents included a journey map to document the member experience from the perspective of three actors and a digital gap analysis to outline digital experiential differences between the outgoing and incoming PBM providers.
How We Did It
Through analysis of multiple documents and conversations with stakeholders and Subject Matter Experts (SMEs), the team was able to develop an overall Member Experience Journey as well as insights into potential member experiences for the PBM Transition.
Documents that were considered:
2018 Medicare Advantage: Health and Drug Plan Disenrollment Reason Survey Results
Prior Authorization Intended Experience
Digital Gap Analysis (Outgoing PBM and the Incoming PBM)
Member Intended Experience
Preliminary Member Risk Assessment
Voice of the Customer Insights - Commercial Member Pharmacy Experience
To ensure a complete view into the experience, our team gathered information and data from seven different workstreams. They each played a critical part in the member journey and were important to understand how members would experience the migration.
Clinical
Prior authorization / ePA / ePrescribing
Formulary & UM / Steo Therapy / Clinical Programs
Quality Assurance (HEDIS / NCQA)
Network
Retail Network / Mail Order
Specialty Rx Network
Fraud, Waste, and Abuse
Benefits Set-Up
Account Group Structure
Benefit Design Configuration
Technology / Data (IT)
Eligibility
Benefits
Group Data
AGL 2.0 UI
Reporting
Servicing
Member Experience / Portal
Data Exchange
3rd Party Data Exchange
Accumulators
Encounters (MA specific)
Operational Readiness
Claims, Enrollment, and Billing
Cross-functional-servicing, Rx, Backend, and Support Operations
Finance / Rebates
Finance
Rebate Reconciliation (includes MA)
Go-to-Market Readiness
Marketing / External Communications
Sales Strategy / Product
External Training
Stakeholder (group, member, provider) Experience
Assumptions / Context
The research focused solely on commercial member experience, not Medicare Advantage
Research conducted did not include primary research (ie. hearing directly from the member)
Recommendations were not final design decisions. They were suggestions to be considered based off experience principles.
Detailed Findings
Frequency
Will the new experience impact journeys of most members or only a select group?*
*guided by data and VoC calls
Impact
Will this change cause an experience abrasion that is easy or difficult to overcome?
Persistence
Is this impact a one-time occurrence or something members will repeatedly experience?
Key Moments for the Member Experience
Member gets overwhelmed by too much information upfront and misses changes that are relevant to them.
Member ages into Medicare after PBM migration.
Member has an issue with their benefits and does not know what to do.
Member is not aware of the PBM Migration and finds out unexpectedly
Member runs into issues with Prior Authorization
Member runs into issues with Step Therapy
Member runs into issues using Home Delivery
Member needs access to previous information (under the outgoing PBM).
Summary of Considerations
A. Communicate PBM changes at multiple moments throughout the journey to ensure member awareness and preparedness.
B. Direct members to additional information for those who seek a comprehensive understanding of the purpose behind the PBM migration.
C. Reaffirm that the PBM migration will not disrupt the current benefit experience in order to ease anxieties about the potential impact.
D. Communicate important information in bite-sized chunks in order to make content digestible and easily understood.
E. Make contact information explicit in order to help members understand where they can find answers to their questions.
F. Make it clear that the member does not need to take any next steps in order to reduce ambiguity in the process.
G. Show relevant and tailored information related to the changes of the PBM migration in order to provide transparency on the impacts for each member.
H. Communicate the purpose and value behind the PBM migration in order to help members understand the benefits of the change.
I. Help members understand what the next steps are to provide transparency in the process.
J. Communicate with members through multiple communication channels in order to ensure member awareness and preparedness.
K. Help members understand the benefits and challenges of available options so they can determine what's best for them.
Applying Considerations to Member Communications
Onboarding Letter
Description of the PBM migration and why it is important.
Highlights of the benefits of the new PBM.
Sent with Formulary and Network Changes Insert.
Links and QR code to insurance client website page with additional PBM migration information.
Relevant Considerations: A, B, C, D, E, F, G, H
Social Media Post
Awareness of the PBM migration.
Links to the insurance client website for additional information about the PBM Migration.
Relevant Considerations: A, B, D, H
Automated Phone Call
Informs members of the PBM migration.
Gives members an option to speak with a CSR.
Informs members that they will receive a new pharmacy card.
Can also be triggered when a new prescription is filled as a reminder to bring their new pharmacy card.
Relevant Considerations: A, B, H
Post Card
Briefly informs members of the PBM migration.
Has a QR code that links to insurance client website page with PBM migration information.
Relevant Considerations: A, B, D, E, H
E-Blast
Informs members of the PBM migration.
Links to insurance client website page with additional PBM migration information.
Outlines the specific impacts that the PBM migration will have on each member
Relevant Considerations: A, B, C, D, E, F, G, H
Text Message
Informs members of the PBM migration.
Links to insurance client website page with additional PBM migration information.
Can also be triggered when a new prescription is filled, a reminder to bring their new pharmacy card.
Relevant Considerations: A, B, D, H
Interactive Voice Response
Automated message when member calls the insurance company
Informs member of the PBM migration.
Gives member the option to speak with a CSR.
Relevant Considerations: B, D, H
Pharmacy Card & Letter
Letter informs members of the PBM migration.
Card has a sticker on it that says “Do not use until 1/1/22”
Sent with Formulary and Network Changes Insert.
Relevant Considerations: B, C, D, E, F, G, H, I
Formulary & Network Changes Insert
Sent with other communications such as the Onboard letter, Explanation of Benefits, Pharmacy Card, etc.
Contains brief information about formulary and network changes.
Links and QR code to insurance client website page with additional PBM migration information.
Relevant Considerations: A, B, C, D, E, F, G, H
Insurance Company Website
In-depth Information about the insurance company and a microsite on the PBM Migration.
Relevant Considerations: A, B, C, D, E, F, G, H, I, J, K
Our Actors
The Output (client names obscured)
The PBM Customer Journey
How to Read Guide:
Because of the sheer number of elements animating in and out of the artboard, please cache a version of the guide in your browser (run it once through), to see it as intended. Client mentions are blurred for privacy.
Future State (Phase 2)
As we wrapped up the assessment for the current state of PBM (2021 - 2022), we pivoted to the future state (2023+) with a focus on what our members expectations were for their pharmacy benefits and how we could remove the friction and create an overall more seamless experience. The challenges of the current experience around 3rd party vendor integration, digital experience touchpoints, affordability and communication continued to be issues that we would probe on for the next phase of work. As part of this, for our members, we devised a way to remotely conduct mini-focus group workshops…
