Improving the overall efficiency for a Pharmacy Benefit Company

Improving the overall efficiency for a Pharmacy Benefit Company

Client: One of the largest pharmacy benefit management organizations (PBM) providing pharmacy benefit management services including network-pharmacy claims processing, industry-leading home delivery and specialty pharmacy services.

Business Problem: The client wanted to drastically improve the way services were managed across the enterprise. The key challenge was replacing a manual processing approach that was error-prone, time intensive and frustrating to the staff. People had to call a variety of numbers to make enquiries. Processing was often paper-driven and disjointed which required several hand-offs between teams.

Our Solution: To meet this challenge, the application was built using the Pega Customer Service platform which provided a seamless transition across communication channels without losing context. Paper-driven processing was first enhanced by integrating Pega with Kofax. The inbound fax would generate cases that would kick off a data entry step. Bar code information would be used to display the appropriate form in Pega. The system would then leverage the data entered to interpret the request and distribute work to the appropriate teams, thus limiting the number of hand-offs. Reuse was strongly emphasized throughout the project which allowed us to leverage the same processing logic, validation, interfaces and UI components when exposing forms to the web channel. The Pega Web Mashup feature was used to embed the Pega forms on the corporate website. This allowed the customer to perform the data entry step on the web and kick off the creation of the case upon submission. Validation was applied before the case was created, allowing the customer to make the necessary corrections.

Benefits to Client: The solution enabled process automation, straight-through processing while increasing Customer Satisfaction, increasing Customer Retention and decreasing training time of customer service representatives.

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