As retiree healthcare costs rise and the Medicare Part D redesign takes shape, 2026 marks a turning point for Employer Group Waiver Plan Prescription Drug Plans (EGWP PDPs). Now is the time to shift from staying compliant to staying ahead.
A high-performing EGWP PDP requires more than just administration, it demands deep clinical expertise, operational precision, and strategic foresight. As a 5-Star EGWP PDP, Pharmacy Benefit Dimensions (PBDRx) aligns clinical, financial, and operational strategies with evolving Centers for Medicare and Medicaid Services (CMS) requirements to help health plans, brokers, and PBMs navigate what’s ahead.
Phase One – Select the Right Partner
Success starts with the right PBM. Key metrics to evaluate their credibility and capability include:
- CMS Star Rating status
- Audit scores
- Prescription drug event (PDE) acceptance ratings
- In-house expertise and regulatory capabilities
- Seamless coordination of eligibility, claims, and servicing
Your PBM should lead with clarity, care, and flexibility to deliver a strategic, high-performing plan tailored to your needs while serving as both an administrator and trusted partner to ensure compliance and value.
Phase Two – Align Strategy
Once your PBM partner has been selected, strategic planning will begin. This includes:
- Eligibility confirmation
- Wrap coverage determination
- Define plan structure
- Formulary and network selection
A strong PBM handles CMS filings, bid submissions, and regulatory compliance to minimize your workload while maximizing results.
Phase Three – Plan Build and Implementation
Effective implementation depends on coordination between the plan, PBM, and CMS. Coupled with proactive, attentive support at every level, go live is the time to ensure the EGWP PDP runs smoothly. Key components include:
- Plan configuration
- File transmission
- Preparation of CMS-required communications
- Delivery of I.D. cards, member communication, and informative resources
- Testing, testing, and more testing
Your chosen PBM partner will interface with CMS, setting the plan up for a successful, compliant, and timely submission of data files. Proven EGWP PDP experience goes a long way at this phase, ensuring maximum value and minimal disruption.
Phase Four – Continuous Support and Improvement
Success doesn’t stop at go live. Throughout the life of the partnership, your PBM should provide trusted expertise by way of:
- Round-the-clock support for the plan, its beneficiaries and their providers
- Regular performance reviews to identify opportunities for optimization
- Real-time enrollment and eligibility reporting
- CMS submissions and compliance audits
A forward-thinking PBM continuously monitors plan performance, anticipates regulatory shifts, and uncovers new opportunities for savings while maintaining compliance and beneficiary satisfaction.
Partner for the Future
EGWP PDPs offer substantial savings and sustained value when built with strategy and executed with precision. As regulations and CMS requirements evolve, PBDRx is here to help you stay ahead.
