Own Your Environment: Take Control of the Way Your PBM Does Business

In this white paper, we’ll explore how Pharmacy Benefit Managers (PBMs) can leverage flexibility, innovation, and strategic partnerships to transform their business operations. We outline the foundational elements of rules, hierarchy, and reporting, and provide you with critical questions to evaluate your adjudication partner’s alignment with your evolving organizational needs.

The Role of Rules

The Foundation of PBM Operations

Rules, often referred to as plan design, are the algorithms dictating plan management, claims processing, and service delivery. These rules are essential for ensuring workflow efficiency, accuracy, and adaptability within PBM operations.

Challenges with Inflexibility

However, the landscape of rules is fraught with challenges stemming from inflexible infrastructures and one-size-fits-all solutions. The repercussions of such inflexibility are manifold:

  1. Lack of Customization: Inflexible systems fail to accommodate the unique nature of diverse employee benefits, leading to suboptimal healthcare delivery.
  2. Slower Response to Market Changes: Dynamic healthcare markets require swift adaptation to regulatory updates and shifting consumer needs, which rigid systems cannot provide.
  3. Operational Inefficiency: Labor-intensive processes to implement changes increase operational costs and delays, affecting service quality and compliance.
  4. Barriers to Innovation: Rigid systems hinder the testing and implementation of new strategies, stifling innovation and competitive edge.
  5. Difficulty in Scaling Operations: Growing businesses face challenges in managing multiple plans and services with inflexible systems.
  6. Compliance Risks: The stringent and evolving regulatory environment necessitates flexible systems to avoid legal and financial risks.
  7. Member and Client Dissatisfaction: Inflexibility leads to dissatisfaction among members and clients, resulting in potential loss of business.

A flexible and dynamic rules engine, like Cervey’s, is not just advantageous; it’s essential for thriving in today’s healthcare landscape. Such an engine distinguishes a struggling PBM from one that sets the industry pace.

Key Questions for Your Adjudication Partner

When assessing your adjudication partner, consider these critical questions:

  • How easy is it to implement changes to our unique plan management?
  • Can global rules be adjusted without disrupting individual plan nuances?
  • Does the engine cater to the majority while recognizing outliers?

Rethinking Hierarchy

Traditional Structure

Historically, PBM hierarchies have been static and cumbersome, characterized by:

  • Fixed Tiers and Levels: A top-down approach with rigid roles and responsibilities.
  • One-Size-Fits-All Frameworks: Pre-existing structures that do not account for specific group needs.
  • Complex Modification Processes: Extensive manual efforts required for any changes, leading to slow adaptation.

Towards a Dynamic Hierarchy

With a flexible adjudication partner like Cervey, PBMs can transcend these limitations and adopt a dynamic hierarchy tailored to business demands.

Key Questions for Your Adjudication Partner

When discussing hierarchy with your adjudication partner, ask:

  • How rigid is our current hierarchy, and what are the implications of making changes?
  • Can we reconfigure employer groups or change TPAs seamlessly?
  • Can we achieve the necessary granularity to reflect our unique business model?

The Value of Flexible Reporting

Importance of Reporting

Flexible reporting is crucial for PBMs to access and utilize data effectively. The benefits include:

  1. Informed Decision-Making: Customized data analytics enable rapid strategic decisions.
  2. Enhanced Client Service: Tailored reports improve service levels and client relationships.
  3. Operational Efficiency: Automated reporting processes save time, reduce errors, and increase accuracy.
  4. Regulatory Compliance: Adaptable systems ensure compliance with changing regulations.
  5. Competitive Advantage: Real-time data helps identify trends, adjust strategies, and maintain a competitive edge.

Cervey’s intuitive and customizable reporting tools go beyond basic reporting to highlight trends, savings, and operational gaps.

Key Questions for Your Adjudication Partner

When evaluating reporting capabilities, consider:

  • Are we restricted in our reporting capabilities?
  • Can we receive both pre-configured reports and raw data for analysis?
  • Can our system meet specific data requests reliably?


The ability to “Own Your Own Environment” as a PBM hinges on selecting an adjudication partner that offers the flexibility, adaptability, and granularity necessary for modern healthcare management. Control over rules, hierarchy, and reporting propels your business forward, ensuring operational efficiency and client satisfaction.

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