For payers, the future requires building a sustainable data alignment strategy

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data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> </div> </div> </div> <div class="tab"> <div class="row"> <div class="row component column-splitter"> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Belgium</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/nl-be" data-variantfieldname="Link">Dutch</a> </div> </li> <li> <div class="field-link"> <a href="/fr-be" data-variantfieldname="Link">French</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Czech Republic</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/cs-cz" data-variantfieldname="Link">Czech</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Denmark</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/da-dk" data-variantfieldname="Link">Denmark</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">France</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/fr-fr" data-variantfieldname="Link">French</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Germany</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/de-de" data-variantfieldname="Link">German</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Hungary</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/hu-hu" data-variantfieldname="Link">Hungarian</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Italy</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/it-it" data-variantfieldname="Link">Italian</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Netherlands</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/nl-nl" data-variantfieldname="Link">Dutch</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Norway</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/nb-no" data-variantfieldname="Link">Norwegian</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Poland</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/pl-pl" data-variantfieldname="Link">Polish</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Portugal</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/pt-pt" data-variantfieldname="Link">Portuguese</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Romania</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/ro-ro" data-variantfieldname="Link">Romanian</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Slovakia</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/sk-sk" data-variantfieldname="Link">Slovak</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Spain</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/es-es" data-variantfieldname="Link">Spanish</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Sweden</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/sv-se" data-variantfieldname="Link">Swedish</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">United Kingdom</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-gb" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> </div> </div> </div> <div class="tab"> <div class="row"> <div class="row component column-splitter"> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Australia</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-au" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">China</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="https://www.wolterskluwer.cn" data-variantfieldname="Link" target="_blank" rel="noopener noreferrer">Simplified Chinese</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Hong Kong</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-hk" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">India</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-in" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Japan</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/ja-jp" data-variantfieldname="Link">Japanese</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Malaysia</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-my" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">New Zealand</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/en-nz" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Philippines</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div 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</div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Taiwan</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/zh-tw" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 class="language-selector-modal__country-name">Thailand</h6> <div class="language-selector-modal__page"> <span class="language-selector-modal__page-name">Home page:</span> <ul> <li> <div class="field-link"> <a href="/th-th" data-variantfieldname="Link">English</a> </div> </li> </ul> </div> </div> </div> </div> </div> <div class="col-12 col-md-3"> <div class="row"> <div class="component link-list"> <div class="component-content"> <h6 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With workflows optimized by technology and guided by deep domain expertise, we help organizations grow, manage, and protect their businesses and their client’s businesses.</p> <a href="/en/tax-and-accounting" class="ow-nav-level-2-view-all-link"><span>Tax & Accounting Overview</span><span aria-hidden="true" class="wk-icon-arrow-right"></span></a> </div> </div> <div class="ow-primary-nav-items"> <div class="ow-primary-nav-item"> <div class="ow-primary-nav-content"> <h6 class="ow-nav-level-2-list-heading">Solutions</h6> <ul class="ow-nav-level-2-list "> <li class="ow-nav-level-2-list-item ow-nav-level-2-list-item-with-text"><a href="/en/solutions/tax-accounting-us" class="ow-nav-level-2-link">Tax & Accounting U.S. Hub</a><span class="ow-nav-level-2-text">Central hub for all U.S. solutions</span></li> <li class="ow-nav-level-2-list-item ow-nav-level-2-list-item-with-text"><a href="/en/solutions/cch-axcess" class="ow-nav-level-2-link">CCH Axcess™ Suite</a><span 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...</span> </li> </ol> </nav> </div> </div> </div> </div> </div> </div> </div> <div class="container-fluid"> <div > <div class="row"></div> </div> </div> </div></div></div> </div> </header>   <main> <div id="content" class="container"> <div class="row"> <div class="row"><div class="component article-header col-12"> <div class="component-content"> <div class="image field-image"></div><div class="container no-padding"><div class="col-lg-10 offset-lg-1 no-padding"><div class="eyebrow"><span class="interest-area field-name">Health</span><span class="date field-editorial-publish-date">November 20, 2024</span></div><h1 class="title field-title">For payers, the future requires building a sustainable data alignment strategy</h1><div class="author-section"><span>By: </span><span class="author-link field-author-name" data-dm-wk="newsheader.link"><a title="allison-combs" href="/en/experts/allison-combs">Allison Combs</a></span></div></div></div> </div> </div> <div class="row component column-splitter"> <div class="col-12 col-md-8 col-lg-1 sticky-wrapper"> <div class="row"> <div class="component social-share vertical col-12"> <div class="component-content"> <div class="share-sticky"><div class="share-wrapper"><div class="share-btn share-btn-linkedin" aria-label="Share on Linkedin"></div><div class="share-btn share-btn-twitter" aria-label=" Share on Twitter"></div><div class="share-btn share-btn-facebook" aria-label="Share on Facebook"></div><div class="share-btn share-btn-mail" aria-label="Share with Mail"></div><div class="share-btn share-btn-print" aria-label="Print"></div><div class="share-btn share-btn-link" aria-label="Copy Link"></div></div></div> </div> </div> </div> </div> <div class="col-12 col-md-8 col-lg-6"> <div class="row"> <div class="component row-splitter"> <div class="container-fluid"> <div > <div class="row"> <div class="component image file-type-icon-media-link col-12 indent-bottom"> <div class="component-content"> <a title="Image 1" href="#" target="_blank"><image height="1024" stylelabs-content-type="Image" alt="Rear view at business analysts discussing work results or performance" stylelabs-content-id="2532804" width="1536" thumbnailsrc="https://contenthub.wolterskluwer.com/api/gateway/2532804/thumbnail" src="https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4" srcset="https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4&t=w507l 507w,https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4&t=w628l 628w,https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4&t=w634l 634w,https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4&t=w735l 735w,https://assets.contenthub.wolterskluwer.com/api/public/content/2532804-rear-view-at-business-analysts-discussing-work-results-or-performance-9993409c4f?v=63ea88e4&t=w768l 768w" loading="lazy" data-variantitemid="{E511EAD2-DBCC-4305-9B64-44DCD5DD4C9C}" sizes="(max-width:539px)507px,(max-width:767px)735px,(max-width:991px)634px,(max-width:1199px)628px,(max-width:1440px)768px,768px" format="" data-variantfieldname="Image" /></a> </div> </div> </div> </div> </div> <div class="container-fluid"> <div > <div class="row"> <div class="component rich-text article-text indent-top"> <div class="component-content"> <p class="abstract">Data alignment between payer benefit teams remains a challenge. Leaders need to build sustainable strategies to best understand improvements for efficiencies and member experiences.</p><h2>Complex data structures require new strategies</h2><p>Medical and drug benefits used to be more clean-cut, resulting in siloed teams, coding structures, and benefit designs. The system was built to accommodate clear delineations between prescription medication and medical treatments.</p><p>However, over time, drug therapies have rapidly evolved—in both scale and complexity—requiring these models to transform. Specialty drugs in the form of <a href="/en/expert-insights/understanding-biologics-biosimilars-impact-on-health-plan-formularies">biologics and biosimilars</a>, as well as <a href="/en/expert-insights/glp-1-medications-and-weight-loss-help-patients-navigate-beyond-trends">GPL-1 and semaglutide products</a>, have blurred the lines between medical and drug benefits, especially when products can be self-administered.</p><p>Additionally, <a href="/en/expert-insights/bridging-value-gap-aligning-medical-drug-benefits">different coding models and structures</a> have complicated information sharing between teams. Pharmacy benefit teams and their systems operate with National Drug Codes (NDC) and medical benefit teams operate in condition code sets like ICD-10 for diagnoses, HCPCS for non-physician services, and CPT for medical procedures.</p><h3>Challenges with drug code mapping</h3><p>Tying to consistently translate between these codes at scale is a challenge. Pharmacy teams need to better understand why a provider is requesting a drug or what medical causes may be triggering a prescription. Data analysts often use crosswalks and the <a href="/en/solutions/medi-span/about/gpi">Medi-Span® Generic Product Indicator (GPI)</a> to translate back and forth between medical conditions and code databases and then back into NDC codes. Billing can also be a challenge as the drug units and/or package sizes often have to be translated between the code sets and in alignment with <a href="https://standards.ncpdp.org/" target="_blank">NCPDP standards</a>.</p> </div> </div> <div class="component image file-type-icon-media-link col-12 indent-bottom"> <div class="component-content"> <a title="Image 2" href="#" target="_blank"><image height="1024" stylelabs-content-type="Image" alt="General flow between NDC and ICD-10 codes" stylelabs-content-id="2542218" width="1536" thumbnailsrc="https://contenthub.wolterskluwer.com/api/gateway/2542218/thumbnail" src="https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750" srcset="https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750&t=w507l 507w,https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750&t=w628l 628w,https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750&t=w634l 634w,https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750&t=w735l 735w,https://assets.contenthub.wolterskluwer.com/api/public/content/2542218-general-flow-between-ndc-and-icd-10-codes-ccf917e971?v=50f7c750&t=w768l 768w" loading="lazy" data-variantitemid="{E4664276-E1E1-4907-98FC-5292F2F07BDD}" sizes="(max-width:539px)507px,(max-width:767px)735px,(max-width:991px)634px,(max-width:1199px)628px,(max-width:1440px)768px,768px" format="" data-variantfieldname="Image"></image></a> </div> </div> </div> </div> </div> <div class="container-fluid"> <div > <div class="row"> <div class="component rich-text article-text col-12 indent-top"> <div class="component-content"> <p>With these siloed data sets and processes, payers and pharmacy benefit managers (PBMs) have challenges <a href="/en/expert-insights/coding-alignment-to-support-whole-person-health">seeing their members’ whole health picture</a>, which can lead to inefficiencies, inaccuracies, and—at times—a frustrating customer experience. Members themselves may get caught between medical and pharmacy claims, especially when a drug can be covered by both pharmacy and medical benefits. Drugs with prior authorizations or patient-safety-based quantity edits can also be challenging to resolve. Creating a clear data alignment strategy to <a href="https://www.wolterskluwer.com/en/expert-insights/payers-future-requires-building-sustainable-data-alignment-strategy/#form">connect pharmacy and medical benefit teams</a>—as well as the rest of the organization—will be critical for payers to move forward in a rapidly changing ecosystem.</p><h2>Key data alignment strategies for payers and PBMs</h2><p>As teams start aligning data within their organization, it will be important to consider the outcomes on equity, scalability, and flexibility—and to find the right data partner to meet these goals. This can be a challenge, particularly for PBMs, which are designed to process pharmacy claims only and do not often have access to the medical claims data for the payers they support.</p><h3>Removing data silos to improve equitable outcomes and reduce costs</h3><p>One of the most challenging strategies to implement will be smoothing out data silos and coding processes. Removing siloes and creating clear, interoperable data transfers is essential to understanding member populations and their medical and drug expenditures more clearly. This allows payer teams to identify opportunities for efficiencies, optimize formularies and policies, and create smoother experiences for payer and PBM teams.</p><p>With full pictures of data, health conditions, and prescriptions, teams can better address member populations and target care based on social drivers as well as claims. With the Centers for Medicare & Medicaid Services (CMS) implementing new <a href="/en/expert-insights/what-does-the-cms-health-equity-index-mean-for-payers">health equity standards in 2027</a>, more accessible data will be essential to leverage for success. Specifically, aligned data across benefit teams and departments will be key to understanding members as a whole person with complex social, economic, and medical factors. Data will be essential to have a holistic picture of member populations, improve Stars ratings and HEDIS scores, and design and implement earlier, effective interventions and support programs.</p> </div> </div> <div class="component rich-text article-text col-12"> <div class="component-content"> <h3>Implementing scalable tools and processes</h3><p>The healthcare industry continues to rapidly change. Medical knowledge <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116346/" target="_blank">doubles every 73 days</a>, the number of drug approvals in 2023 hit <a href="https://www.nature.com/articles/s41587-024-02166-7" target="_blank">an all-time high</a>, and projections anticipate <a href="https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/the-use-of-medicines-in-the-us-2024" target="_blank">50-55 new medications and therapies</a> launching each year through 2028.</p><p>Changing regulations can toss curveballs into data strategies and require teams to pivot at scale. Recent CMS regulations like the <a href="https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f" target="_blank">Transparency in Coverage Final Rule</a> and the <a href="https://www.cms.gov/nosurprises" target="_blank">No Surprises Act</a> can require process adjustments—with a clean data strategy, teams can stay agile and revise approaches.</p><p>As these trends accelerate, payers need to be able to scale alongside them. Having the <a href="/en/solutions/uptodate/industries/health-plans-payers">right technology solutions</a> and processes in place to provide the latest information and support coding interoperability, like the <a href="/en/solutions/medi-span/about/gpi">Generic Product Indicator</a>, will be necessary to translate claims and prescriptions between teams. Scaling up member engagement and education materials will also require clean data strategies to be able to provide personalized content when claims include ICD-10 codes indicating certain medical cases.</p><h2>The right data partner is critical for current and future success</h2><p>Data alignment is crucial for better customer and member experiences, and to improve internal processes of payer and PBM teams. While daunting, the right data partner can help make the transitions smoother and support implementation. With the <a href="/en/solutions/medi-span/who-we-help/payers-and-pharmacy-benefits-managers">Medi-Span drug data solutions</a> and aligned <a href="/en/solutions/uptodate/industries/health-plans-payers">clinical information and member engagement</a> from UpToDate® solutions, the team at Wolters Kluwer is ready to support data strategies across your organization for more seamless data exchange and preparation for the future. </p><p><i>Learn more about data alignment strategies by downloading the whitepaper “Bridging the value gap: Aligning medical and drug benefits for health insurers”, and explore </i><a href="/en/solutions/medi-span/who-we-help/payers-and-pharmacy-benefits-managers"><i>drug data solutions for payers and pharmacy benefit managers</i></a><i>.</i></p> </div> </div> <div class="component plain-html col-12"> <div class="component-content"> <span id="form"></span> </div> </div> <div class="component wk-container col-12 alternate-background indent-bottom"> <div 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