A quick snapshot, so we start from the same page

• Tell me briefly which three specialty launches and timeframe prompted this review
• How many covered lives does the affected benefit population include? Options: Under 50,000, 50,000 to 250,000, 250,000 to 1,000,000, Over 1,000,000
• Who on your team is the day to day owner for formulary maintenance and P&T preparation? Options: Pharmacy Director, Clinical Pharmacist lead, Pharmacy analyst, Benefits manager, Shared role across teams, Other
• Which recent formulary change required an emergency policy or fast-track approval? Options: New high-cost launch, Biosimilar substitution, Safety alert, Regulatory mandate, None in last 12 months
• Roughly how long do you expect your review and decision cycle for new specialty drugs to take today? Options: Under 2 weeks, 2 to 6 weeks, 6 to 12 weeks, Over 12 weeks

If costs kept rising, where would you feel it first

• If those three launches run without any clinical criteria, which budget metric would first force an immediate restriction? Options: Absolute pharmacy spend increase, Per member per month budget, Specialty spend as percent of total, Reserve fund depletion, Regulatory threshold breach
• How many percentage points of pharmacy budget increase would you consider a trigger for emergency action? Options: 1-2%, 3-5%, 6-8%, Over 8%
• When budget pressure rises, who in your organization must sign off before criteria are tightened? Options: Pharmacy Director alone, Pharmacy Director and Medical Director, VP Benefits, Legal/compliance plus clinical, Full executive committee
• Which downstream process tends to break first when specialty spend spikes, claims accuracy, member appeals, or P&T meeting pace? Options: Claims accuracy, Member appeals volume, Committee meeting cadence, Pharmacy network disputes, Other
• What single outcome from a short proof of concept would make you sign a contract that week?

Who really runs formulary governance at your organization

• Who ultimately approves clinical criteria for new formulary entries and how consistently does that path get followed? Options: P&T committee, Pharmacy Director with Medical Director concurrence, Medical leadership alone, Shared governance with external advisors, Ad hoc approvals
• Walk me through the typical P&T packet for a new specialty drug, what documents and analyses are always included?
• How often does your P&T committee audit prior authorization denials to check clinical alignment and appeal trends? Options: Monthly, Quarterly, Twice a year, Annually, Not routinely audited
• Who prepares the budget impact model and who validates it before committee distribution? Options: In-house pharmacy analytics, Finance team, External consultant, Shared responsibility, Not prepared consistently
• If the committee process lacks one thing right now, what single governance gap would stop this project immediately?

The provider and member view, and why it matters

• Describe the member appeals or provider complaints you worry about most when access is restricted
• How many provider complaints or state regulatory inquiries did you receive in the last 12 months related to formulary decisions? Options: None, 1-2, 3-5, 6-10, More than 10
• Which stakeholder reaction would create the biggest political risk inside your organization, physicians, members, regulators, or senior leadership? Options: Physicians, Members, Regulators, Senior leadership, Payers or brokers
• When you limit access for clinical or cost reasons, who is most likely to escalate and how is that handled? Options: Provider relations team, Appeals team, Clinical leadership, Legal/compliance, Not escalated consistently
• Which single provider or regulatory consequence would make you pause a rollout immediately?

What measurable signals will prove success to the people signing checks

• Which quantitative outcome does your VP of Benefits care about most, budget percent reduction, appeals volume, or committee cycle time? Options: Budget percent reduction, Appeals volume reduction, Faster committee cycle time, Improved NCQA alignment, Other
• How quickly do you need to see measurable impact after cutover to consider the project successful? Options: Within 30 days, 30 to 90 days, 3 to 6 months, 6 to 12 months
• What threshold of estimated annual savings would justify the implementation cost to your CFO or finance committee? Options: Under $250k, $250k to $1M, $1M to $3M, Over $3M
• Which reporting cadence and audience would satisfy governance review, P&T, finance, or executive updates? Options: Weekly operational reports, Monthly P&T pack, Quarterly executive summary, Ad hoc on request
• If the first pilot fails to hit its targets, what decision rule will your leadership use to continue, pause, or stop the rollout?

Integration and data reality check

• Which claims adjudication system and pharmacy interfaces must accept changes for a successful cutover, and who owns those connections? Options: Claims adjudication engine, PBM claims interface, Pharmacy network gateway, Internal integration team, External IT vendor
• Are programmatic APIs available for your claims and eligibility data, and who controls API credentials? Options: APIs available, credentials with internal IT, APIs available, credentials with vendor, Limited APIs, requires manual extracts, No APIs currently
• Imagine a three month migration window, which integration gap would block that timeline today, missing API, data mapping, or approvals? Options: Missing APIs, Unmapped data fields, No data owner approvals, Testing environment not available, Other
• Who will be your primary technical point of contact for configuration, testing, and cutover decisions? Options: Internal IT lead, Pharmacy systems analyst, Third party integrator, Clinical informatics lead, Shared team
• Which environment must be ready for a parallel claims run, test, acceptance, or production? Options: Test environment, Staging environment, Parallel production, None available yet
• What single missing technical prerequisite would stop integrations from proceeding?

Data quality and migration attention points

• When we migrate formulary and criteria, which data artifacts worry you most, mappings, historical tiers, or prior authorization rules? Options: Field mappings, Historical tier assignments, Clinical criteria rules, Member-level overrides, Other
• How clean and accessible is the source formulary data, fully normalized, partially normalized, or inconsistent across files? Options: Fully normalized, Partially normalized, Inconsistent, Not sure
• Who is authorized to sign off on migrated criteria versus who can request corrections after cutover? Options: Pharmacy Director, Clinical team, IT data owner, Joint sign off
• Have you ever experienced a migration that produced claim denials or incorrect coverage rules during transition? Options: Yes, once, Yes, multiple times, No, Not sure
• What process must be in place to prevent mission critical data mismatches during cutover? Options: Parallel claims testing, Manual reconciliation, Automated validation scripts, Other
• If the migration introduced even a small number of incorrect approvals, what would your tolerance be before pausing the rollout? Options: Zero tolerance, Under 0.1% of claims, Under 0.5% of claims, Under 1% of claims, Higher tolerance

What has gone wrong before, and what you learned

• Tell the story of the last time a formulary change created a provider complaint or regulatory inquiry, what happened and who escalated it?
• How long did it take to resolve that issue and what were the operational costs in staff hours? Options: Under 1 week, 1 to 2 weeks, 2 to 4 weeks, Over a month
• Which internal control or approval would have prevented that incident in hindsight? Options: Stricter clinical criteria review, Faster provider notification, Better testing with claims, Clearer governance sign off, Other
• Who lost confidence after that event, clinicians, leadership, or external partners? Options: Clinicians, Senior leadership, Members, External partners, No confidence lost
• Which single after-action change would reduce the chance of recurrence enough for you to proceed with a new vendor?

Competitive landscape, the other options on the table

• Which alternatives are you currently evaluating, incumbent PBM, other vendors, or an internal rebuild? Options: Internal build, Incumbent PBM, Other third party vendor, Consulting engagement, No clear alternative
• What would have to be true about your current incumbent for you to stay with them instead of switching? Options: Lower net cost, Stronger clinical governance evidence, Faster integration timeline, Better provider relations, Other
• Has anyone on your team proposed solving this without an outside vendor, and if so what was the proposed scope? Options: Yes, full internal build, Yes, partial internal tooling, No internal proposal, Discussed but not approved
• Which competitive worry matters most to you, incumbent relationships, implementation risk, or clinical credibility? Options: Incumbent relationships, Implementation risk, Clinical credibility, Cost competitiveness
• What single advantage would keep you with the incumbent even if another option matched price?

Decision criteria and timeline, who signs and when

• If a pilot demonstrates the projected budget and clinical controls, what process would get you to signature and who needs to sign?
• Which contract terms or legal approvals typically lengthen your procurement, indemnity, data sharing, or SLA terms? Options: Indemnity, Data sharing agreements, Service level agreements, Payment terms, Other
• How soon does your organization require an executed contract after pilot acceptance to meet your regulatory or benefit design windows? Options: Immediately, Within 2 weeks, 2 to 6 weeks, Longer than 6 weeks
• Who are the non negotiables for the commercial and legal review that must sign off before implementation? Options: Legal, Finance, Privacy/compliance, Executive leadership, All of the above
• What single missing commercial or governance condition would stop you from moving forward even if the pilot hits targets?

• Solution Experience Session

• Confirm the current state and its cost
• You confirm the demonstrated cost model produces the granularity and accuracy needed to support the VP of Benefits' decision.
• Run the sample cost-impact analysis on the provided three specialty launch scenarios and deliver the results, assumptions, and sensitivity ranges before the follow-up session.
• You confirm the automated committee workflow removes the spreadsheet and email steps that cause delays and inconsistent criteria.
• Run cost-impact modeling on your launch scenario
• Provide the list of the three launch drugs, current utilization and cost per member, and the P&T schedule for the next 60 days.
• You agree on the remaining data and integration evidence required before a purchasing decision can be made.
• Walk through the automated committee workflow using a live request
• Export current clinical criteria and tier mappings for the impacted drugs and share field-mapping documentation for the claims adjudication engine.
• Show clinical criteria authoring and downstream publication to claims
• Prepare a mapping proof-of-concept that publishes one clinical criterion to the claims endpoint and capture the parallel test results for the next meeting.
• Validate fit and confirm acceptance criteria

• Solution Experience Session
• Solution Experience Deck
• Solution Brief

• meeting
• slides
• document

• Migrate Formulary Data to the Platform
• Configure Clinical Criteria and PA Templates
• Author and Publish Step Therapy and PA Rules
• Configure Tier Structures, Copays, Quantity Limits
• Implement Therapeutic Substitution and Biosimilar Conversions
• Integrate with Claims Adjudication Endpoint
• Run Parallel Claims Sync and Cutover Validation
• Automate P&T Committee Workflow and Decision Capture
• Deploy Monthly Formulary Publication Automation
• Enable Compliance Reporting and NCQA Audit Trails
• Publish Rebate-Independence Governance Records
• Train Pharmacy Operations and P&T Committee

Migrate Formulary Data to the Platform

• How many formulary line items (unique National Drug Codes NDCs or GPI therapeutic groups) need migrated from your current formulary export? Options: Less than 5,000, 5,000-25,000, 25,000-100,000, More than 100,000
• Which data sources contain your authoritative formulary and clinical criteria (e.g., current formulary CSV export, clinical criteria repository, claims mapping table)? Options: Formulary CSV export, Clinical criteria repository, Claims mapping table, Pharmacy benefit file (legacy PBM), Other
• Who is the data owner for formulary line items and prior authorization templates (name or role) responsible for final sign-off on migrated records?
• When is the effective date window we must respect for migrated changes (for example next P&T committee date or state filing deadline)? Options: Within 30 days, Within 60 days, Align to next P&T meeting, Specific state filing window (describe)
• Do you require a migration acceptance threshold (for example >=99% NDC mapping accuracy and zero critical clinical criteria mismatches) and reconciliation evidence such as a migrated vs source report? Options: Yes, we require a numeric threshold and reconciliation report, No, sign-off can be ad hoc

Configure Clinical Criteria and PA Templates

• Provide the list of clinical guideline sources you require referenced in authored criteria (for example National Comprehensive Cancer Network NCCN, American College of Cardiology, FDA label). Options: NCCN, FDA label, Society guideline (specify), Internal clinical policy, Other
• List the types of prior authorization templates to configure (for example oncology cycle-based PA, specialty pharmacy referral, biosimilar substitution exception).
• Estimate the number of distinct PA templates and clinical criteria rules to author, grouped by therapeutic category. Options: Less than 50, 50-150, 151-300, More than 300
• Confirm whether your templates must include dosing windows, required prior therapies, and required diagnostic codes (ICD-10) for P&T review and claims enforcement. Options: Yes - include all three, Yes - include some, will specify which, No - fewer requirements
• Specify any NCQA or state-level clinical requirements that PA templates must document such as timeliness, notice language, or required data fields.

Author and Publish Step Therapy and PA Rules

• Identify which therapeutic classes require multi-step therapy algorithms versus single-step prior authorization; list by therapeutic class or GPI.
• Select standard step therapy actions you want available during rule authoring (for example automatic override for generics, require trial of biosimilar first, specialty pharmacy referral) Options: Automatic generic override, Biosimilar-first requirement, Specialty pharmacy referral, Manual clinical review required
• Describe the evidence threshold your P&T committee expects to allow clinical overrides in step therapy (for example specialist attestation, documented failure of prior therapy, chart review).
• State the expected publication cadence for step therapy and PA rule updates to the claims system (for example monthly or immediate post P&T approval). Options: Immediate (within 48 hours), Weekly, Monthly, Quarterly, Other
• Attach or paste a sample prior authorization form, step therapy exception form, or a typical rule sheet we should use as an authoring template.

Configure Tier Structures, Copays, Quantity Limits

• Indicate the number of formulary tiers and copay structures you currently use (for example 3-tier, 4-tier specialty, coinsurance for specialty). Options: 1-2 tiers, 3 tiers, 4 tiers, 5+ tiers
• Will you require bulk tier changes during migration and do you want bulk update scripts versus manual editing? Options: Yes - provide bulk scripts, No - prefer manual review, Discuss hybrid approach
• Are there branded versus biosimilar copay differentials to implement and what are the copay amounts by tier?
• What quantity limit rules must be encoded per therapeutic class (for example 30-day supply units, dosing-based quantity limits tied to weight or cycle)?
• Include any state-mandated quantity limits or refill authorization windows that must be enforced at claims adjudication. Options: Yes - state mandates apply, No - none, Unsure, need review

Implement Therapeutic Substitution and Biosimilar Conversions

• Name the biosimilars and reference biologics you want substituted automatically or routed to a biosimilar-first step (list by product name and NDC/GPI if available).
• Report any existing interchangeability designations or payer-specific substitution policies you currently follow for biosimilars.
• Measure the target conversion rate or budget impact goal for biosimilar substitution (for example 20-30% savings or a dollar target) to evaluate success metrics. Options: Target % savings (specify), Target $ savings (specify), No explicit target
• Choose where substitution enforcement should occur: at point of sale, during prior authorization, or only by formulary-tier placement. Options: Point of sale, Prior authorization, Tier placement only, Combination
• Detail any manufacturer or state notification requirements when substituting biologics such as dispensing notices or record retention obligations.

Integrate with Claims Adjudication Endpoint

• Outline the technical endpoint type we will integrate with for adjudication (for example REST API to adjudication engine, NCPDP Telecommunication batch feed) and provide available specs. Options: REST API, NCPDP Telecommunication, Flat file batch, Other
• Break down the data elements required for mapping to the claims endpoint (for example NDC, tier code, prior authorization indicator, quantity limit code, effective date).
• Match your claims system identifier for formulary items (for example NDC, HRI, GPI) to the platform field we will populate. Options: NDC, GPI, HRI, Custom identifier
• Calculate or confirm the acceptable service level agreement SLA for rule propagation to claims (for example within 24 hours of P&T approval) and define the test success threshold for live cutover (for example 99.9% adjudication parity).
• Prioritize adjudication endpoints by cutover order if multiple exist (for example retail claims first, specialty pharmacy second). Options: Retail first, Specialty first, Simultaneous, Other

Run Parallel Claims Sync and Cutover Validation

• How many days of parallel claims processing do you require to validate parity with the legacy adjudication system (for example 7 days or 14 days)? Options: 3 days, 7 days, 14 days, 30 days
• Which test cases must be included in parallel testing (for example specialty drug denials, step therapy approvals, biosimilar substitutions, quantity limit overrides)? Options: Specialty denials, Step therapy approvals, Biosimilar substitutions, Quantity limit overrides, Other
• Who on your operations team will own cutover decision authority and real-time escalation during parallel runs (name or role)?
• When can we schedule a staged cutover to avoid regulatory filing windows or P&T blackout periods? Options: Before month-end, After P&T meeting, Outside state filing windows, Flexible - discuss
• Do you require automated reconciliation reports comparing claim adjudication outcomes and member financial impact during parallel runs? Options: Yes - automated daily reports, Yes - manual reconciliation only, No

Automate P&T Committee Workflow and Decision Capture

• Provide your current P&T committee cadence, attendee roles, and approval thresholds that must be modeled in the workflow.
• List the meeting artifacts that must be captured in the platform for each P&T review (for example agenda, evidence packet, voting record, conflict of interest disclosures). Options: Agenda, Evidence packet, Voting record, Conflict of interest disclosures, Other
• Estimate the average number of drug reviews per committee meeting that must flow through the automated workflow. Options: 1-5, 6-15, 16-30, 30+
• Confirm the acceptance criteria your P&T committee requires on published clinical criteria such as documented literature citations, conflict of interest declarations, and required voting evidence. Options: Standard citations + COI + voting log required, Some elements required, will specify, No formal acceptance criteria
• Specify mandatory voting thresholds or National Committee for Quality Assurance NCQA evidence-documentation fields that must be surfaced for each committee decision.

Deploy Monthly Formulary Publication Automation

• Identify destination systems for automated monthly publications (for example claims adjudicator, provider portal, member ID card file). Options: Claims adjudicator, Provider portal, Member ID file, Public website, Other
• Select the publication formats required for monthly publication (for example NCPDP SCRIPT, CSV mapping feed, human-readable PDF). Options: NCPDP SCRIPT, CSV feed, PDF snapshot, XML, Other
• Describe the change approval gating required before publication (for example P&T approval, medical director sign-off) and who provides final sign-off.
• State the required versioning and archival retention period for published formulary snapshots for audit purposes. Options: 1 year, 3 years, 5 years, Custom
• Attach a sample published formulary file or feed specification to be used as the target format for automation.

Enable Compliance Reporting and NCQA Audit Trails

• Indicate the NCQA and state audit artifacts you need captured for each formulary change (for example meeting minutes, conflict of interest disclosures, clinical citations, change logs). Options: Meeting minutes, COI disclosures, Clinical citations, Change logs, Other
• Will you require scheduled compliance reports such as monthly NCQA packages or ad hoc state audit bundles and at what frequency? Options: Monthly, Quarterly, Ad hoc on request, Other
• Are there specific report templates your compliance team expects (for example CSV audit log, PDF committee docket) that we must produce? Options: CSV audit log, PDF committee docket, Custom template required, No template required
• What retention period and access controls must be enforced for audit trails to satisfy NCQA and state regulations? Options: 1 year, 3 years, 5 years, Other
• Include any external auditors or third-party reviewers who must be granted read access to audit artifacts and specify the access scope. Options: Internal compliance only, External auditors, State regulator portal, Public disclosure

Publish Rebate-Independence Governance Records

• Name the governance documents you require published to demonstrate rebate-independence such as conflict of interest policy, P&T charter, and meeting minutes.
• Report the level of redaction or public disclosure required for rebate negotiation materials versus clinical deliberation records. Options: Full disclosure of clinical records, redacted financials, Limited internal disclosure only, Public summary only, Other
• Measure the granularity of governance records you need for external review (for example per-drug conflict disclosures, per-meeting voting logs). Options: Per-drug disclosures, Per-meeting voting logs, High-level summaries, Other
• Choose the audience for published governance records such as internal compliance, state regulator portal, or public website. Options: Internal compliance, State regulator, Public website, Provider partners
• Detail who on your team must approve governance disclosures before publication and the approval SLA.

Train Pharmacy Operations and P&T Committee

• Detail the user groups that require training such as formulary pharmacists, claims editors, P&T committee members, and benefits managers and expected class sizes.
• Outline preferred training modalities (for example live workshop, recorded modules, train-the-trainer) and timing relative to cutover. Options: Live workshop, Recorded modules, Train-the-trainer, Blended
• Break training into required modules such as criteria authoring, committee workflow, claims mapping, and cutover playbook and indicate which are mandatory. Options: Criteria authoring, Committee workflow, Claims mapping, Cutover playbook
• Match operational job functions to system permissions needed for go-live (for example who can publish, who can edit clinical criteria, who can approve changes).
• Calculate the number of training hours per role and any post-go-live support windows required such as a 30-day hypercare period. Options: Less than 4 hours, 4-8 hours, 8-16 hours, More than 16 hours

• Master Services Agreement (MSA)
• Order Form / Subscription Agreement
• Statement of Work (SOW)
• Service Level Agreement (SLA)
• Data Processing Agreement (DPA)
• Business Associate Addendum (BAA)
• Data Access & Transfer Authorization
• Governance & Roles Charter
• Acceptance Criteria & Cutover Sign-Off
• Change Order Agreement

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate and Incumbent Decommission (around day 90)
• Quarterly Success Review (ongoing)

• Document any regulatory timing constraints affecting upcoming formulary changes and propose mitigation steps.
• Restate acceptance criteria and numeric targets
• Produce a documented acceptance decision that records pass or fail for each numeric target from Solution Scope.
• Confirm the incumbent system is decommissioned or retained read-only with data archived or migrated and no operational fallback in use.
• For any failed criteria, lock in remediation tasks and verification dates to reach acceptance within the agreed extension window.
• Publish the formal acceptance record that lists each criterion, pass/fail status, and the named buying signatory.
• Execute the incumbent decommission checklist including contract termination or retention terms, data archival confirmation, and communication to users.
• Open remediation tickets for any failed criteria with clear acceptance-verification steps and target completion dates.
• Outcomes review versus Solution Scope targets
• Confirm the solution continues to meet or make progress toward the Solution Scope targets for spend variance and P&T-to-claims publication time.
• Maintain a prioritized backlog with clear resolution timelines so open compliance and enhancement items are progressing.
• Identify any operational or regulatory risks that require mitigation and document the agreed actions for the next quarter.
• Update the shared backlog with priorities, expected completion windows, and acceptance verification criteria for each item.
• Schedule targeted reconciliation checks for claims publication latency and deliver a short report mid-quarter.
• Re-confirm success criteria and ownership
• Confirm that cutover tasks completed and data migration reconciles within agreed tolerances documented in Solution Scope.
• Identify and prioritize any critical blockers with concrete remediation tasks and target verification dates.
• Verify initial adoption signals show end users are accessing the platform and running P&T workflows.
• Publish the post-cutover validation report including reconciliation summary and outstanding issues.
• Execute prioritized remediation tasks for critical defects and schedule verification checks by the agreed dates.
• Enable and share short-term usage telemetry dashboard for committee activity and claims publication counts.
• Present first measurement data
• Establish whether specialty drug spend trajectory and formulary-to-claims discrepancy rate are trending toward Solution Scope targets.
• Document root causes for each significant gap and a remediation plan with completion dates.
• Confirm timeline and required evidence to reach the acceptance gate at day 90.
• Produce a metric workbook that shows calculation methodology and source data for spend and discrepancy metrics.
• Implement the agreed corrective configuration or integration fixes and log verification checkpoints.
• Run a targeted claims reconciliation job and deliver the reconciliation report before the acceptance gate meeting.
• Deployment and migration validation
• Backlog and compliance tracker review
• Review P&T documentation completeness
• Present outcome data against each criterion
• Root-cause diagnosis for gaps
• Document pass or fail per criterion and acceptance decision
• Recurring operational risks and regulatory timing
• Early adoption signals and usage patterns
• Agree corrective actions and timeline to acceptance gate
• Open issues and blockers
• Incumbent system decommissioning confirmation
• Agree next quarter remediation and monitoring actions
• Agree remediation plan for any failed criteria
• Agree immediate remediation actions