Is Your PBM Switch Set Up to Succeed? Start With These 7 Questions.

Avoid the chaos. Protect your people. Make the switch with confidence.

3 Min read
July 7, 2025

Tricia Bancroft

Senior Director, Brand Marketing & Communications

Best Practices

Switching Pharmacy Benefit Managers (PBMs) can feel like walking a tightrope—one misstep, and suddenly your inbox is flooded, your employees are confused, and trust is on the line.

But it doesn’t have to be that way.

At LucyRx, we’ve helped countless organizations navigate PBM transitions smoothly. And we’ve learned this: the difference between a seamless switch and a stressful one often comes down to asking the right questions—early.

7 essential questions every HR leader should ask before switching PBM’s:

1. How will you match our current formulary to minimize employee disruption?

Formulary mismatch is the quickest way to lose employee trust. If your employee shows up at the pharmacy and hears “not covered,” the damage is done.

A strong PBM will map your current formulary to theirs, identify any gaps, and propose clear alternatives before go-live.

💡 Pro tip: Ask for a formulary disruption analysis. It’s a simple step that can prevent a lot of pain.

2. Can we mirror our existing pharmacy network—or improve it?

Pharmacy access is personal. If a trusted local pharmacy suddenly drops out of network, employees will notice—and not in a good way.

Look for a PBM that offers flexibility: the ability to mirror your current network, expand access, or optimize based on utilization.

What to look for: Options, transparency, and a clear explanation of trade-offs.

3. Will you review our SPD and claims data to identify gaps or mismatches?

Your Summary Plan Description (SPD) should match what’s actually happening in your claims—but too often, it doesn’t.

Misalignment can lead to denied claims, compliance concerns, and frustrated employees.

A great PBM will audit both your SPD and claims data to catch inconsistencies before they become problems.

4. What’s your process for converting specialty medications—who handles it, and when?

Specialty meds are high-risk: they’re costly, complex, and often urgent.

The right PBM will proactively coordinate with prescribers, notify patients, and ensure continuity of care. They should also support Open Refill Transfer Files (ORTFs) for both mail-order and specialty prescriptions.

Ask this: Will you support ORTF for specialty meds? If not, why not?

5. How and when will our employees be notified about the switch?

Communication makes or breaks transitions, No employee should hear about the change at the pharmacy counter.

Look for a PBM who will deliver clear, timely, and human-centered communications—not jargon-heavy language.

Bonus points: Digital ID cards, pre-go-live FAQs, and direct pharmacy outreach are all signs of a thoughtful transition.

6. Who owns rejected claims after go-live—and how quickly are they resolved?

The first 30 days post-launch are critical. Rejected claims will happen—but they should be resolved quickly.

What to ask: What’s your process for daily reject review and real-time resolution?

A partner should own the resolution path with clear accountability and rapid response.

🚩 Red flag: If they say, “we’ll monitor it,” ask for specifics. Vague answers are risky.

7. What does your support model look like in the first 30 days?

Go-live support isn’t a “nice to have”—it’s the difference between confidence and chaos.

Look for: Daily updates, proactive pharmacy coordination, and a dedicated point of contact who knows your plan inside and out.

You need a partner who’s in the trenches with you—not just handing off a checklist.

The Bottom Line

Switching PBMs doesn’t have to mean disruption.

With the right partner—and the right questions—you can lead with confidence, protect your people, and deliver the kind of prescription care your workforce deserves.

At LucyRx, our implementation model is built for clarity, continuity, and care. So your employees barely feel the change—because everything just works.

Ready to pressure-test your plan? No pressure—just clarity.

Schedule a transition consultation

Is Your PBM Switch Set Up to Succeed? Start With These 7 Questions.

3 Min read

Tricia Bancroft

7 essential questions every HR leader should ask before switching PBM’s:

1. How will you match our current formulary to minimize employee disruption?

2. Can we mirror our existing pharmacy network—or improve it?

3. Will you review our SPD and claims data to identify gaps or mismatches?

4. What’s your process for converting specialty medications—who handles it, and when?

5. How and when will our employees be notified about the switch?

6. Who owns rejected claims after go-live—and how quickly are they resolved?

7. What does your support model look like in the first 30 days?

The Bottom Line

Ready to pressure-test your plan? No pressure—just clarity.

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