A conversation with Beth Hebert-Silvia: PBM transition brings new opportunities

This month, we sit down with Beth Hebert-Silvia, managing director of pharmacy, to get her thoughts and insights on some of the early successes and upcoming opportunities from our recent transition to pharmacy benefit manager (PBM) Prime Therapeutics on January 1, 2017.

What positive changes can our employers and their employees expect to see from their pharmacy benefits and coverage starting in 2017?

This transition was successful for our employer groups, with several positive enhancements taking place behind the scenes. One of the greatest benefits to working with Prime is that we’ll have the ability to tailor a program to an employer’s specific needs and budget. We’ll be able to customize pharmacy benefits with options such as alternate formularies, tier designs, mail order strategy, and pharmacy networks, with the goal of minimizing the amount of member disruption.

A couple of exciting enhancements include electronic provider prior authorizations (ePA) and real-time accumulators. ePA is a new web feature available to our providers to ease their administrative burden. Real-time accumulators enable BCBSRI to track deductible dollars across medical and pharmacy benefits, establishing best-in-class capabilities to our members. We will offer enhanced clinical programs, continued integration with our specialty pharmacy vendors, dedicated account management support, and advanced analytics.

Self-insured employers will be able to take advantage of reporting suites not previously available, as well as comprehensive analysis and consultation to help them make informed decisions about their healthcare benefits. This level of information and insight into a group’s usage and claims can answer the all-important “so what” question. Any PBM can provide reams of data, but now we can provide analysis to help employers understand what it means.

What are some of the actual numbers and successes we’ve already seen?

Some of our achievements so far have been really compelling. To start, we transferred more than 12 million 2015 and 2016 pharmacy claims to Prime before the transition date. Since January 1, we’ve seen claims come in at a steady, expected rate with an expected to lower than normal rate of rejected claims. For example, in the individual market, rejected claims are down 15% compared to 2016, while in the employer market the rate is on par with 2016.

PrimeMail, our mail order service, has been particularly successful. Through late January, we saw much higher than anticipated utilization with compliments on ease of use and average time from prescription receipt to shipping of less than a day. These results are very encouraging and are the result of a great deal of hard work by BCBSRI and Prime.

By nature, all PBM transitions are challenging. What made this transition process worth it, and how is it structured for success going forward?

First and foremost it’s Prime’s commitment to Blue plans. Their unprecedented wealth of resources, tools, and implementation experience developing pharmacy programs for other Blues assured us that they were the perfect partner for us. Throughout the approximately 15-month transition leading up to January 1, 2017, we were continually impressed by their ability to adjust to our unique needs, and by how clear, deadline-driven, innovative, and collaborative they’ve been.

Internally we’ve had terrific project management and a focused work effort across multiple departments that helped ensure that we met the needs of employers, brokers, providers, and pharmacies. Going forward, we’ll continue to have a dedicated Prime resource available to us to help address any questions or issues that may arise. Our goals were to proactively communicate changes to key stakeholders including employer groups, brokers, providers, and members; prepare our network pharmacies for the change; enhance operational capabilities; ensure benefit accuracies; and deliver new clinical programs into the delivery system, and we achieved all of them!