How Long Should a PBM Implementation Take?

When Abarca Health took over as the full-service PBM for Vital, the Medicaid program managed by the Puerto Rico Health Insurance Administration (ASES), it faced a challenge. The PBM needed to implement the program in just 10 days. But the company was able to meet the challenge and transition essential services, including claims processing, formulary management, and network contracting and payments management, with no disruption in benefits for 1.3 million Medicaid beneficiaries.

Adriana Ramirez

A typical implementation takes about nine months to a year, said Adriana Ramirez, Abarca’s chief operating officer. “For a complex benefit and complex client, we’re talking about multiple months of work,” she said in an interview with Formulary Watch. “There is a lot of the heavy lifting around the configuration work and data exchange, or they would not be able to process claims appropriately.”

A team of about 30 people came together onsite in Puerto Rico, working 18-hour days, to complete the implementation on time. They prioritized data exchange and proper mapping of files.

Ramirez said one of the challenges they faced in such a shortened timeframe was training the more than 200 people from the various managed care organizations who would be using the system. “The team got very creative, creating basic a Q&A and doing very tailored training to specific users,” she said. “We had multiple people physically at the managed care organizations to coach them on the system.”

To reach members, Abarca worked with local pharmacies. The Medicaid program in Puerto Rico serves members through 900 community pharmacies with two or three associations that represent them. Once the implementation was completed, Abarca’s claims team monitored the call center and daily rejected claims, but Ramirez said things went smoothly.

While every implementation is different, she said there are learnings that can be had from this experience. “We’ve seen what’s possible. It was a big sacrifice, but it turned out positively. Going forward, I’m questioning the status quo about how we’ve done things. It’s given us the opportunity to be able to challenge how we manage implementations in general.”

Related: A PBM that Takes on Financial Risk

Abarca is a PBM with a net cost pricing solution, which guarantees the net cost of drugs, including specialty medications, by offering a fixed, per-script cost for a plan’s entire population. This pricing model, Assura, recently was awarded the 2022 PBMI Excellence Award.