A plan sponsor finalizing selection of a new pharmacy benefit manager (PBM), or already preparing for go-live, needs to shift gears quickly to focus on transition. Most members will notice little beyond a new ID card and new contact information. The more pressing challenges often lie with employees who have complex medical needs and take specialty medications, or who have an approved prior authorization.

These members are where support during a PBM transition proves itself. Strong transition support shows up as a specific, verifiable plan for members already in treatment. It is paramount that plan sponsors consider this experience during the RFP and press potential PBMs for documented processes on how they uphold continuity of care.

What Strong Transition Support Looks Like for Members

As more employers than ever before go to RFP with new vendors (one PSG survey reports respondents' likelihood to renew their PBM contract without issuing a competitive RFP fell to 6.4, its lowest point to date), executing transition well will continue to be a top concern for employers. The clearest sign of strong member support during PBM transitions is a PBM that takes three core steps for members in active treatment:

1. It identifies members whose care could be interrupted before go-live.

2. It carries their approvals, refills, and therapy forward where the data allows.

3. It follows through quickly when something does not carry over.

Any lapse will show up in the first weeks. Issues at the pharmacy counter can quickly turn into escalations that reach HR, especially for members with time-sensitive prescription needs. A PBM that can document its process for all three, with named owners and timelines, gives the benefits team commitments it can verify during implementation.

Steady-state service, including call access, support channels, and satisfaction, belongs in a separate review focused on evaluating everyday member support.

Which Members Need Support Before Go-Live

For many members, a transition means a new card, new contact information, and possibly a new mail-order pharmacy. For members that fill medications that require a prior authorization (PA), the incoming PBM should be able to show how it identifies these members before the effective date to ensure care isn't disrupted.

Four groups of members should have a precise plan before go-live:

• Members on specialty therapy, whose specialty pharmacy may change.

• Members with approved or pending prior authorizations, who may face a new review if the approval does not transfer.

• Members with open mail-order or specialty refills, whose next shipment depends on those refills moving to the new pharmacy.

• Members whose current drug changes formulary status, who may need an alternative, an exception, or a new utilization management step.

These members are the most likely to need hands-on help, and they are the ones a plan sponsor most wants protected. Members with specialty medications are a small share of most plans' membership but often manage complex conditions and several medications. That combination makes how a PBM handles its most complex members a practical test of the whole partnership.

Essential Information for Smooth PBM Transitions

Continuity for these members depends on the transition files and information at the center of any full PBM transition. They can include historical claims, open refill transfer files (ORTFs), member census files, and prior authorization files. Ideally, your team requests them, the outgoing PBM supplies them, and the incoming PBM loads them without incident.

The outgoing PBM may not be forthcoming, and files can arrive late or incomplete. For that reason, treat each file as "in progress" until the incoming PBM confirms it was received and is usable. Any disruption analysis is only as reliable as the claims data behind it, so ask when the analysis will be rerun on confirmed data.

Grandfathering and transition-period terms vary by PBM and plan design. Confirm them during implementation, including how specialty drugs and other sensitive clinical situations are handled. The table below pairs each mid-treatment situation with what should carry over and a question that tests the incoming PBM's plan.

These answers demonstrate whether the incoming PBM can resolve a data gap with the member before go-live or leave it for the counter. This is implementation work, shared by the employer's team and the incoming PBM's implementation team. It sets the starting point for the member support that continues after go-live.

Support at Go-Live and in the First Weeks

Go-live is when remaining gaps surface, often at the pharmacy counter. Planning for go-live readiness should cover post-launch commitments as well as member communications. Members should be notified before go-live to present the new ID card at every fill, so the claim processes under the new PBM.

Before go-live, confirm these commitments with the incoming PBM:

• Proactive claims monitoring, including rejections for members flagged as mid-treatment, with escalation before members are affected.

• A service-level agreement (SLA) for resolving member cases and a defined process for prior authorizations not honored at the counter.

• An agreed response time for escalations HR raises on behalf of employees.

• A staffing plan for the higher call volume expected in the weeks after go-live.

• Early reporting on speed to answer, call volume, and abandonment, plus successful fills and resolved escalations.

Together, these measures give HR a clearer view of the transition. Responsibility also generally shifts at this stage from an implementation team to continuing member support, so ask who owns each commitment after go-live.

How SmithRx Approaches Member Support for Members in Treatment

It's common for benefits leaders to be concerned about the employees who will be in active treatment at go-live. We start by sharing our operational roadmap: how prescriptions transfer, how members are set up, and the exact timing of outreach. We also train client teams to interpret claims transition reports and to understand what members experience during their group's transition or grandfathering period.

We encourage clients to remind members to present their new SmithRx ID card. In our experience, a missing new card is one of the top reasons for day-one calls. When a member needs help, our 100% in-house member-support agents help them navigate and coordinate next steps.

After go-live, we provide comprehensive reporting on fills, member calls, and service wins alongside concerns we flag before the client asks. Our dedication to radical transparency means our HR partners don't need to go hunting for this information: it's at their fingertips through our Partner Portal.

Frequently Asked Questions

Will members need to change pharmacies during a PBM transition?

Whether members change pharmacies depends on the incoming PBM's retail, mail-order, and specialty networks and on the plan's design. Ask the incoming PBM for a list of members whose retail, mail-order, or specialty pharmacy will change, and when each will be notified.

How long does a grandfathering period last after a PBM change?

The length is a contract and plan design decision, so it varies by PBM and is set during implementation. Confirm which medications and approvals the period covers and what members are told before it ends.

What happens if the previous PBM's prior authorization file is incomplete?

Members missing from the file may need a new review under the plan's criteria with the incoming PBM, depending on the plan's transition terms. Ask how the PBM will identify those members before go-live and how it will prioritize urgent cases.

When should employers expect a PBM transition to feel stable?

Stability is a judgment the employer makes from reporting, once rejected claims and HR escalations return to expected levels and open transition cases are closed. The timing varies by plan, so agree on these signals with the incoming PBM before go-live.

Continuity of care for members already in treatment during transition is essential. Evaluating a PBM's preparedness and processes should be a crucial part of any RFP.

Want to learn more about SmithRx's transition and implementation experience? Speak to one of our pharmacy benefits experts.