The Plan Design module allows you to design your PBM plan effortlessly while aligning every detail perfectly with your business needs, with no coding required. With the plan design-based architecture, you become the architect of a unique organization structure, creating and managing PBM plans with unbeatable control, flexibility and simplicity.
Hierarchy Structure
The application uses the following hierarchy structure:
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Organizations
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Carriers
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Groups
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Plans
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Subgroups
The Organizations anchor your structure, linking to multiple carriers, each tied uniquely to one organization for clarity and control.
The Groups create flexible benefit structures, while subgroups let you add precise, member-specific rules, like unique adjudication logic or benefit caps – without disrupting the broader framework.
Changes Made Easy
With a seamless, intuitive process that puts you in charge, it empowers you to shape your structure in real time. Every change from tweaking associations to adjusting dates, can take effect instantly or whenever you are ready, keeping your structure sharp and current.
Seamless Scaling
Throughout plan design, it is designed with cloning, modifying, and breaking down complex rules into simple user-friendly interface.
Structure Visualization
Visualizing your structure is seamless with the Hierarchy Detail screen that displays a vivid grid of your plan’s relationships. View all elements – Org IDs, Carrier Codes, Plan Names – come to life at your fingertips. With intuitive toggle buttons and filters to zoom in on the most important components, analysis has never been this easy.
Easy Collaboration with Export Options
Plan Design enables you to export your structure for easy collaboration and deeper exploration. While ensuring that your PBM plan is clear, accessible, and free of technical barriers, which empowers you to craft a suite of powerful rules. With Age Rules you can enforce coverage of age-dependent medications, streamline accounts receivable with Bill Cost Calculators, or ensure Coordination of Benefits are implemented accurately.
Easy Cost and Claims Management
With the Plan Design module, you can set Copay Rules for affordability, manage costs with dynamic Cost Calculators and predefined Cost Lists, or customize Dispense Fee and Dispense Limit Rules for medication management. Moreover, it allows you to handle additional pricing strategies with Other Amount Claimed rules, streamline workflows with Process Rules. With Special Deductible & Cap protocols via the SDC Manager, you can build add-on benefits for the plan. These rules ensure your plan aligns perfectly with your business and member goals.
Seamless Customization with User-Defined Fields (UDFs)
User-Defined Fields let you customize your plan with custom text, numbers, dates and prepopulated fields.
Robust Auditing Tools
With the application's robust auditing tools, you can ensure transparency with the Timeline feature that tracks every edit in a clear, accessible view, while notes and attachments, complete with timestamps and user details, build a comprehensive audit trail. For documentation and compliance, you can export these details, ensuring your structure remains accountable at every step.
Seamless Integration
Your structure connects seamlessly to real-world operations. Pharmacy specific rules can be applied at the plan level applying specific benefits without altering your broader framework. Carrier or Group levels support ID card configurations and auto-ticketing for rejected claims, integrating effortlessly with systems like Ticket Tracker. This ensures your PBM plan is not just precise, it’s driving efficiency and boosting member satisfaction.
It’s your no-code partner for PBM plan design, blending flexibility, control, and simplicity. Intuitive interfaces with lookup windows, dropdowns, and cloning functionality let anyone shape complex plans with ease. Tailored rules and custom fields craft a structure that reflects your unique needs. Real-time updates and audits keep you dynamic and compliant. Whether you’re a small organization or a sprawling enterprise, you can effortlessly scale up, with cloning and filtering tools to keep your framework cohesive.
With its plan design-based architecture, you’re not just managing PBM plans—you’re crafting a unique organization structure defined by control, flexibility, and precision. This platform empowers you to build tailored, efficient, and compliant plans that meet every business need, from the broadest framework to the smallest detail.