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Processes

What will AGI do for Conduct pharmacy benefit management?

AI-deliverabilitydigital

Because no specific child occupations are seeded, the scalar is derived from the process name 'Conduct pharmacy benefit management' and its industry anchor 'Direct Health and Medical Insurance Carriers'. Managing pharmacy benefits consists of claims processing, formulary management, and policy administration, which is heavily data-driven information transformation work. I assigned a band-center value of 0.85 to reflect this predominantly digital knowledge work.

A member attempts to fill a prescription at a pharmacy or a provider submits a prior authorization request for a medication.

Trigger
A member attempts to fill a prescription at a pharmacy or a provider submits a prior authorization request for a medication.
Outcome
The prescription claim is adjudicated against the member benefits and formulary to determine the covered payment and patient copay.

The work itself

Grounded Work Profile

Measured by

  • Claim Adjudication Cycle TimeprocessProfile
  • Formulary Compliance RateprocessProfile
  • Pharmacy Cost Per Member Per MonthprocessProfile
  • Prior Authorization Turnaround TimeprocessProfile

Key steps

  • Establish and update the medication formulary and tiering structureprocessProfile
  • Negotiate pricing and rebates with pharmaceutical manufacturersprocessProfile
  • Manage the network of retail, mail-order, and specialty pharmaciesprocessProfile
  • Receive prescription claims and prior authorization requestsprocessProfile
  • Adjudicate claims against eligibility, clinical rules, and benefit designprocessProfile
  • Disburse payments to pharmacies and reconcile manufacturer rebatesprocessProfile

How AGI delivers it

Four ways AGI delivers for Conduct pharmacy benefit management

  • Autonomous Agents as digital employees

    Hire a digital employee that does the job under earned, supervised autonomy.

    Agents.do

  • Services-as-Software

    Get the professional outcome delivered as software, priced on results, not headcount.

    Services.do

  • Business-as-Code

    Encode how your work runs, once, as software that executes itself.

    Platform.do

Go deeper

Explore Conduct pharmacy benefit management

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