Not All Change is Equal: Smoother Member Transitions

Amanda Peterson

Humans are creatures of habit. It can be hard to switch to something new, especially if the transition comes with uncertainty — and dare we say it — disruption. HR executives often have such worries when they consider switching pharmacy benefit managers. And they are valid concerns.

Will data from the existing PBM transfer to the new one? Will familiar pharmacy networks still be accessible under the new PBM? Will employees encounter new requirements to access medications?

In other words… Is the promise of a new PBM worth the member disruption?

Let’s define what member disruption is.

We consider disruption to be anything that causes friction in the member’s access to their medication. This can impact not only the member but also the plan sponsor, if the plan sponsor is asked to help resolve the complaint. It can create a burden for both the member and the plan sponsor, adding work to both their plates.

No one wants this. HR departments want to keep their employees happy. They especially don’t want a change in PBM to negatively affect their employees’ health and wellbeing. That’s why reducing disruption to the greatest extent possible is a high priority.

It’s also a key priority for us.

Not all change is equal. The keys to minimizing member disruption are thorough preparation and active management.

What causes disruption?

New Formulary

Introducing a new formulary is the biggest potential challenge in any PBM transition.

Different PBMs, or plans within a single PBM, often employ different formularies. A key disruption arises when a drug that was available on a previous PBM’s formulary is no longer offered on the new PBM’s formulary. A variation of this problem is when that drug is placed on a higher cost tier of the new formulary.

New Utilization Management

When new utilization management requirements are introduced — such as prior authorizations, quantity limit, or step therapies — that didn’t exist on the previous PBM’s formulary structure, it is often experienced by the member as disruptive.

How we manage transition: Disruption Report, Transition Plan, Transition

Disruption Report

Forewarned is forearmed: The first thing WithMe Health does when it works with a new client is to thoroughly analyze client data to identify those members that will be impacted by the change. We always look at this for all members. This thoroughness distinguishes us from many of our competitors, who will often do this for some segments of the population but not others.

Our goal is to identify members who might experience disruptions when moving to our formulary and management programs, from drugs no longer covered to new step edits and prior authorizations. We also identify members who pick up medications at pharmacies not in our network.

Fortunately, the percentage of members who face disruption from a formulary change is generally no higher than two percent of a group’s covered lives.

Having developed this disruption report, we collaborate with our clients to develop a transition plan.

Transition Plan

The best transition plans are developed in collaboration with an engaged client. This is because transitions require thoughtful tradeoffs between member experience and financial considerations: decisions best made by the client to align with their population management goals. But also because a client’s engagement with their own member population to educate and communicate about the transition greatly improves the member’s experience of the process. Below are three key aspects of the transition plan.

1. Member Experience vs. Financial Considerations:

The timing of a formulary transition has an impact on cost and member experience. It’s essential for us to work with the client to understand what their ideal balance of these considerations is.

Hard conversion: The sooner a member switches to our formulary, the greater the potential savings. This is a reason to choose the hard conversion. If a sponsor’s priority is to take advantage of lower cost medications immediately, then it makes sense not to have a “grace” period.

In this case, the switch to the new formulary becomes effective at the same time as the new PBM is operational. It can be a more abrupt and disruptive experience for members, but yields quicker financial impact.

Soft conversion: A “soft” conversion is one that enables the grandfathering of prescriptions for a period that can last between 30 to 90 days after the new PBM is operational. During this time, members are allowed to continue taking their current medications. (In rare cases, we will indefinitely grandfather a member’s medication, particularly for mental health drugs or seizure medications where there is a very narrow therapeutic index.)

This time cushion enables a number of interactions which make the experience of the transition smoother for members. It gives us a longer window to try to inform the member about the changes and educate them on their options. It gives the member more opportunity to have a discussion with their provider about the change and decide on their next steps.

But a grandfathering period does delay the financial impact that is often the original impetus behind a change in PBM in the first place.

2. Education & Communication

Outside of weighing the tradeoffs around timing, our client’s engagement can significantly help in other ways as well. We’ve observed that clients who have a greater understanding of how formularies work are especially adept at educating employees on the value the changes provide. They help their employees know what’s coming and what to expect. Education and communication are key to smoothing the member’s transition.

3. Network access: Meeting the member where they are (at their pharmacy)

We identify pharmacies that are being used by our incoming members that are not in our existing network of 65k pharmacies nationwide. In these rare circumstances, we’ll attempt to sign contracts to bring these pharmacies into our network. If we succeed, the member won’t even be aware that there was the potential for disruption. They will be able to continue doing what they have done before with no disruption.

If the pharmacy is unable to contract with us, we’ll provide members with a list of alternative pharmacies in their ZIP codes or as close as possible. And in this case, we’ll help to facilitate the transfer of the medications to that new pharmacy.


Having identified impacted members, and then developed a plan for the timing of and outreach around the transition, we reach a period where the rubber hits the road.

Our impacted members’ experience of this transition is only as good as our outreach. But superior outreach is a core capability at WithMe, and we are proud of how well-equipped we are to do this.

Members agree: we have an 87 Net Promoter Score, well above the PBM average of less than 10.

We are able to begin our outreach to impacted members as soon as we have the members’ contact information and the channels through which we are able to reach out rely on the information we are given. We always have the members’ addresses and are always able to send a letter. But having their phone numbers - especially mobile - equips us for better outreach. Armed with this information as well, we are able to contact members by text or call.

Our team of Medication Guides — pharmacists and pharmacy technicians who support members throughout their medication journey — begin their relationship with impacted members as soon as we are operational as your PBM. Our Guides are both clinical experts and highly trained in the psychology of relationship-building. They operate with empathy and a goal of building trust.

This is non-trivial when an insurance company is communicating news of a disruptive change. It is not a welcome message for a member to receive. How it’s communicated matters.

When a phone conversation is possible, it offers so many opportunities for insights into a member’s health, life context, and goals. This insight in turn helps the Guide to be a better problem solver where there is room to do so. When there are multiple options of clinically appropriate medications or geographically appropriate pharmacies, the Guide is able to understand the “color” around a member’s life that helps the Guide make targeted recommendations. When a member is well-informed and well-advised the first time, it significantly limits disruption.

One way or another, our priority is making the member aware of the changes and letting them know we are here to support them.

Our committed approach to outreach stands in stark contrast to that of most other PBMs, whose communication around change is often limited to the sending of a single letter. In our opinion, this is a box checking exercise, not a sincere attempt to communicate or support the member.

To recap: What’s the WithMe Difference?

  1. Thorough preparation

  2. Commitment to client collaboration

  3. Member communication: empathetic, committed, constructive

These tenets underpin the right way to manage member transition during a PBM change. How that change is managed makes all the difference in the experience.

And they are the backbone of our process because, while any change has the potential to create problems, not all change is alike. Our actions can have an outsized impact on the experience and at WithMe, and we’re dedicated to making it a good one.