Healthcare: Pharmacy Benefit Managers
Focus on Customer Health to Significantly Lower Your Costs
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The Challenge: With the rise in consumer-driven healthcare and the spotlight on costs and reform, Pharmacy Benefit Managers (PBMs) need to deliver smarter, more efficient service than ever before to retain members, offset eroding pricing power and maintain market leadership.
With Pega, PBMs can rapidly transform their business to deliver outstanding member and provider experiences at substantially lower cost. Dynamic, intent-led processes can personalize each interaction, guiding members to the most cost-effective protocol, helping them use their medications correctly and enhancing drug management by automatically identifying treatment conflicts. At the same time, Pega’s intelligent automation connects all of the data, systems, processes and channels needed to complete work so that you can streamline formulary management, automate clinical guideline compliance and promote shared-business processes to bring better visibility and control to plan sponsors and prescription drug manufacturers alike.
Learn more about Pega solutions for:
- Care Management – This transformational solution enables PBMs to efficiently develop and manage high-touch programs for diverse populations, customizing and delivering individualized care plans such as Drug Utilization Review through a unified portal.
- Customer Relationship Management (CRM) – Pega CRM makes it easy to provide consistent, personalized service over any channel with intelligent processes that tailor the interaction to the member or provider, situation and channel.
- ICD-10 – Pega facilitates accurate ICD-10 coding with intent-led processes that guide users through the steps for determining the right code. Combined with conversion tables, reverse mapping, translation rule creation and ICD reporting and modeling, Pega helps healthcare organizations rapidly complete successful conversions from ICD-9.
- Medicare/Medicaid - Pega’s intelligent automation drives efficiency, consistency and agility into the complex processes required to execute and manage Medicare and Medicaid programs such as Medication Therapy Management, enabling error-free processing and immediate adjustment to changing regulations.
Customer Success | |
| Becoming an Agile Enterprise In his keynote address to PegaWORLD 2010, Kenneth Klepper (President and Chief Operating Officer of Medco Health Solutions Inc.) discussed how business transformation is an imperative to achieve the goal of an agile enterprise. In a truly agile enterprise, funding and resources for transformation must flow to the point of accountability. And this means fundamentally rethinking the way we fund, measure, and manage both IT and business resources. Having achieved significant success in Six Sigma, the Pharmacy Benefit Manager's story tells of a new plateau of agility to which all organizations can aspire. |
 | Prescription Solutions Offers New Online Prior Authorization Service for Physicians and Health Care Professionals “We have made it possible for our Claim and Prior Authorization systems to ‘talk’ to each other in order to improve service for physicians. This is just one of the many ways we are applying innovative technologies to improve administrative efficiency, giving physicians more time to spend with patients,” said Joseph Addiego, M.D., Prescription Solutions’ senior medical director. |
 | Removing Risk in a High-Risk Business Pharmacare, a CVS/Caremark company, gave this presentation at PegaWORLD detailing the use of Pegasystems' BPM technology to create a solution to be used by both Pharmacare and Caremark while the two were being merged. Used in all the Pharmacy Benefit Managers' pharmacies, the automated dosage calculator was deployed in just 30 days. The solution optimizes specialty drug dosages to minimize product waste and their associated costs. Read the case study |
