From new employee onboarding processes, to targeting and conducting outreach to Medicare Part D beneficiaries as part of a Medication Therapy Management Program, Pegasystems’ Business Process Management Suite (BPMS) can help Pharmacy Benefit Managers (PBMs).

The PBM industry has grown exponentially over the past few years, fueled by the introduction of Medicare Part D and the unprecedented growth of generics and specialty drugs. It will only continue to grow as the baby boomers enter their “golden years”, shooting drug utilization through the roof and requiring the one-on-one healthcare support that only PBMs can offer.

This is a pivotal time for PBMs. With the global economy in crisis and the President’s spotlight on U.S. healthcare costs, the PBM industry is taking an ever-increasing leadership role in healthcare reform. PBMs need to be smarter and more efficient than ever before to offset eroding pricing power. This is a time when there will be a clear separation between winners and losers. The winners will be those who become more efficient and also differentiate themselves by offering specialized services to patients, providers, their payers and self-insured sponsors, and manufacturers alike.

Cost Efficiency. With patient volume increasing at geometric levels, keeping up with growth will be an on-going challenge. The spotlight on healthcare spending in these times of economic crisis makes it more important than ever for PBMs to contain costs. This means:

Efficiently moving patients to lower cost solutions, from brand to generic drugs and from retail pharmacy sales to mail order services in a seamless, systematic manner.
Effectively working with providers and plan sponsors on responsive Formulary management, streamlining processes so that cost containment formulary decisions are easier to deploy
Automating clinical guidelines, so high cost pharmacists and clinicians aren’t used for manual tasks.
Enhancing drug rebate management by systematic identification of opportunities and elimination of manual tasks thereby optimizing cost recoupment potential.

Adding new value. Bringing the right drugs to the people who need them while saving them money is the first step. Now, there’s more being asked of PBMs to improve people’s health, including:

Focused specialty drug management, and other clinical programs where pharmacists and physicians use technology to identify treatment conflicts, to reduce the risk of adverse events, to ensure drugs prescribed are appropriately used, to optimize therapeutic outcomes through improved medication use, and apply their specialized knowledge to those with multiple chronic diseases.
Improved patient education and involvement to ensure patients are filling their prescriptions, taking their medications as prescribed, and to help eliminate barriers to maintenance medication refills.
Providing effortless personalization and robust business process outsourcing capabilities to plan sponsors and manufacturers to optimize their interactions with patients through the use of the PBM’s branded systems.

Find out more about Pega and PBMs...

Solutions In Action


Rapid Deployment for Member Surge	Personalized and Responsive Service	Automatic Resolution Spurs New Productivity	Paperless System and CMS Compliance
Real-Time System Boosts CRM	Automation and Call Centers	100% Straight Through Processing	Safety, Compliance, and Automation
New Value Comes to Old Systems	Personalized and Responsive Service	Headcount and Training Time Reduced	Automated Claims Processing
Quick Solution Captures New Customers	CRM Grows to 98% Customer Satisfaction	Average Handling Time Cut by 26%	Benefit Coding Compliance