How the Right PBM Can Boost the Member Experience—and Star Ratings

March 11, 2021

By Peter Cummings and Bob DiRenzo

As member ratings, complaints and other experience measures take on added weight in the Medicare Stars program, having the right pharmacy benefit management is critical for drug plans.             

Medicare is putting the magnifying glass on members' satisfaction with their prescription drug plans. How will your plan hold up to the scrutiny?  

Starting next year, measures related to members' experiences of their pharmacy plan will drive more than half of the Part D Star rating—more than 50% higher than the current weight. While this new methodology won't be reflected until the 2023 Star ratings come out, plans shouldn't waste time preparing, given the importance of high Star ratings to attract new members and receive quality bonus payments.

Plans should be asking themselves: Are members reporting problems obtaining prescription drugs, or getting frustrated by unexpected high copays? Are they seeking more convenient access to their medications, such as through home delivery? Can members easily navigate our offerings, or do they feel lost in a labyrinth of uncoordinated programs?

Pharmacy plans can deploy several tactics to bolster their relationships with members, such as offering lower out-of-pocket costs, implementing member concierge services, and promoting self-service digital tools that educate members on their pharmacy benefits. However, plans should not overlook the foundational role of their pharmacy benefits management (PBM) partner. Whether that PBM is working directly with members or providing back-end support that ensures a seamless, cohesive experience, a PBM partner can either help lift members’ ratings or drag them down.

Here are a few key facets of the member experience where the PBM plays an important role.

Getting Needed Prescriptions

Every year, millions of beneficiaries join a Medicare prescription drug plan for the first time, switch plans, or experience changes to their pharmacy benefits at the start of the year. These members rely on their plans to help them navigate the transition to their new benefits, particularly if the change impacts prescriptions those members have already been taking. Their perceptions can quickly turn negative If there are any snags or surprises when they attempt to fill their prescriptions.

To prevent members from having a negative experience, Medicare prescription drug plans need to provide advanced oversight across eligibility, claims and transition policies. This work, which is often led or supported by PBMs, includes:

  • Educating members, providers and health plan team members of upcoming pharmacy benefit changes.
  • Comprehensively testing and validating pharmacy benefit configurations before the start of a new plan year.
  • Diligently reviewing claims in the first month of the new plan year to identify and quickly resolve enrollment and claims processing issues that may impact access to care.

At the start of 2021, our PBM team identified an enrollment issue occurring with a Medicare Advantage plan that created risk for new plan members to receive a transition fill prescription—the one-time, 30-day drug supply members are allowed after they switch plans or when benefits change at the start of the year. Within hours of identifying a single rejected claim that surfaced the issue, our team coordinated the steps to allow the member to access his transition fill appropriately. We also worked with the plan to correct the enrollment issue, avoiding any further access issues for impacted members. The level of oversight and quick resolution to this access to care issue prevented frustration for any additional members.

Such oversight activities are behind the scenes to members, and their impact goes unnoticed unless claims processing does not go according to plan. Even minor issues can spiral into problems that have a negative impact on how members rate their ability to get prescriptions.



Broadly Implementing Member-Friendly Benefits

Members appreciate pharmacy benefits that make it more convenient and affordable to obtain their medications, such as home delivery of certain medications with $0 copay. But there’s a big difference between deciding to offer such a benefit and having thousands of satisfied members getting their medications shipped to their door.

Plans need the flexibility to tailor their program to promote and administer such benefits. Achieving this level of alignment can require an advanced level of customization that is not easily administered if a plan is utilizing a national formulary offered through a contracted PBM. On the other hand, a PBM that is willing to work hand-in-glove with the plan will ensure that these crucial steps are completed successfully.

Then the hard work begins—effectively informing members of the new benefit, educating them about what to expect and providing tools to take advantage of it. This requires a committed PBM partner.

For example, when Evolent's PBM team helped one Medicare Advantage partner to promote home delivery of $0 copay medications, we not only helped the plan identify the commonly utilized chronic disease management drugs that would be covered by this benefit but also supported the plan on educating their members of the new benefit. Since medications by mail had the potential to improve medication adherence, our team adapted and began promoting the plan-specific benefits of home delivery to members engaged in our medication therapy management (MTM) and medication adherence interventions, which we also oversee for the plan. 

Fostering an Integrated Member Experience

No matter how many high-quality programs a pharmacy plan offers, lack of coordination among them can make for confused and exasperated members. A member who is contacted by a pharmacy team member for a medication adherence intervention may raise other concerns, such as difficulty accessing one of his medications due to a prior authorization requirement. In a well-coordinated model, the pharmacy team member has access to real-time prescription claims data to assess the issue, identify the prior authorization requirement, provide options for covered drugs in the formulary, or initiate the prior authorization on the member's behalf. During that same call, the pharmacy team member may find that the member qualifies for a comprehensive medication review as part of the health plan's MTM program. The team member can inform the member of the opportunity and schedule the medication review for the following week.

_q_tweetable: A PBM provides the building blocks of a positive member experience, through high-quality oversight, the willingness to align the formulary and clinical programs around consumer-centered benefits, and integrated clinical pharmacy programs. _q_ A comprehensive PBM solution makes all this possible, allowing the pharmacy plan to present a unified front to members and improve their experience. Evolent's integrated clinical platform, for example, not only serves as a single source of truth for various pharmacy-related programs, but also population health programs. Our pharmacy experts also integrate with a health plan's member services team to help them quickly resolve member inquiries regarding their pharmacy benefits.

Such effective coordination is difficult when plans delegate responsibility for various Part D Stars-focused programs—such as MTM, adherence and statin use in diabetes—to different in-house or outsourced vendors. The dedicated point solutions may lose sight of the big picture in their hyper-focus on specific measures. In an uncoordinated model, the member may be transferred to a different person to resolve his prior authorization concern, requiring him to explain the issue once again. Additionally, the opportunity is lost to quickly schedule a comprehensive medical review. A different arm of the plan will have to reach out later, but there's no guarantee that member will pick up the phone, in which case the review won’t occur.

A PBM provides the building blocks of a positive member experience, through high-quality oversight, the willingness to align the formulary and clinical programs around consumer-centered benefits, and integrated clinical pharmacy programs. However, it takes dedicated effort and expertise to ensure they are implemented and administered properly. Bringing together the components of a member-focused plan requires a dedicated, flexible relationship with a PBM partner and a truly comprehensive approach.



About the Authors

Peter Cummings  

As senior director of pharmacy and market operations for Evolent Health Services, Peter is responsible for supporting health plans in managing the cost and quality of their pharmacy benefit programs. He has worked with Evolent health plan clients on drug trend management, clinical analytics, population health programs, Medicare operational compliance, and Stars measure performance.

Bob DiRenzo 

As vice president of pharmacy services, Bob is responsible for leading teams who work with clients across all lines of business to improve the financial performance of prescription drug benefits, as well as overall performance of health plans. He is also responsible for maintaining profit and loss responsibility for the department.




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