Snapshot: where your drug spend stands today

• To get started, how would you summarize your current annual pharmacy spend and covered lives in one sentence?
• How many active members are on the pharmacy benefit today? Options: Under 10,000, 10,000–50,000, 50,001–250,000, 250,001–1,000,000, Over 1,000,000
• When was the last time you ran a drug trend decomposition that separates trend, utilization, and net unit cost? Options: Within the last month, 1–3 months ago, 3–6 months ago, More than 6 months ago
• Tell me about the last time a single drug or therapy class materially changed your quarterly forecast, what happened and why it surprised you?
• Which of the following documents can you share for initial scoping, select all that apply? Options: Current PBM contract or summary, Recent rebate ledger or reconciliation, Formulary file or tier list, 12 months of paid claims, None of the above
• Describe the one number in your pharmacy reporting that, if wrong, would cause your CFO to push back on any vendor recommendation.

Where pharmacy costs create the most pressure

• If your specialty spend trend kept rising at the current rate for another year, what would stop you from accepting more of that exposure?
• Which therapy categories are driving most of your specialty spend right now? Options: Oncology, Autoimmune/biologics, HCV/rare disease, Multiple sclerosis, HIV, Other
• How many members filled a specialty drug in the last 12 months? Options: Fewer than 100, 100–500, 501–2,000, 2,001–10,000, More than 10,000
• Walk me through the last episode where prior authorization delayed therapy start, including who noticed the delay first and how long it took to resolve.
• Which member experience metrics do you track that reflect access pain, select up to three? Options: Time to therapy start, Approval overturn rate, Member complaints about access, Abandonment at point of sale, Adherence for specialty drugs
• What single operational failure would make you stop a PBM migration immediately?

Which therapies and formulary levers matter most to your bottom line

• How confident are you that current formulary tiers and step therapy rules are steering members toward lower net cost alternatives? Options: Very confident, Somewhat confident, Neutral, Not confident
• Which formulary tier currently contains the highest percentage of net spend? Options: Tier 1 or generics, Tier 2 or preferred brands, Tier 3 or non-preferred brands, Specialty tier, We do not map spend by tier
• Describe how you currently handle specialty dispensing, including whether specialty claims flow through your medical carve-in, a designated specialty pharmacy, or retail network.
• Which clinical edits or utilization management rules cause the most provider or member friction? Options: Prior authorization, Step therapy, Quantity limits, Refill-too-soon blocks, None of the above
• How large a share of your rebate dollars are reconciled and visible to you today? Options: Fully transparent and reconciled, Visible but partially reconciled, Reported only on high-level totals, Not visible
• If a formulary change could reduce specialty net spend by 10% next year, what internal obstacle would most likely prevent you from approving it?

Transition risks that could stop a switch

• What is the biggest fear your benefits team has about switching PBMs, specifically around member disruption or formulary gaps?
• Which transition issues have you experienced in past changes, pick all that applied? Options: Claims adjudication errors, Formulary loading mismatches, Network access problems, Rebate reconciliation delays, Member communication failures
• When you switched vendors previously, which vendor action or omission caused the longest outage or member impact and how long did it last?
• Who on your side must sign off before you can proceed with a migration, choose all that apply? Options: Benefits director, CFO/finance, Clinical leadership, Procurement, Legal/compliance
• Which single transition failure would make you walk away from a contract conversation right now?

The other options you are actively considering

• Which of the following alternatives are you evaluating instead of partnering with an external PBM? Options: Incumbent PBM contract renewal, Move to full pass-through with a different vendor, Hybrid model with internal claims adjudication, Bring specialty management in-house, No change
• Tell me which incumbents or solution types you have spoken with recently and what the headline difference was in their proposals.
• What would have to be true about staying with your current approach for you to choose not to move to a new administration model?
• Has anyone on your leadership team proposed solving this problem internally without an outside vendor, and if so, what was the proposed route? Options: Yes, build internal capability, Yes, partner with a specialty vendor only, No, outside vendor preferred, Unsure
• Which decision factor among cost, clinical outcomes, member experience, or implementation risk will carry the most weight in your final choice? Options: Total net cost and rebates, Clinical outcomes and safety, Member access and satisfaction, Implementation and operational risk
• If the incumbent agreed to match price but not provide greater transparency, would that be sufficient to keep you with them? Options: Yes, Maybe, No

Practical gates and technical readiness

• Which system integrations are must-haves before go-live, select all that apply? Options: Eligibility feed (834/real-time), Claims feed (837/835 or API), Rebate reporting feed, Provider directory sync, EHR or care management APIs
• Do you currently have APIs or SFTP endpoints available for claims and eligibility, and who owns those endpoints? Options: APIs available, owned by internal IT, SFTP available, owned by vendor, Both available, Neither available
• Describe the person or team who will be the named owner for day-to-day integration and testing, including their bandwidth for a migration project.
• How clean and accessible is the data you expect to provide for the first reconciliation, for example, do you have 12 months of normalized claims with NDCs and paid amounts? Options: Fully prepared and normalized, Mostly prepared with gaps, Partial data, significant cleaning required, Not available
• Which regulatory or compliance approvals could gate the timeline, choose all that apply? Options: Internal legal review, State Medicaid approvals, Data-sharing contracts, Security assessments, None anticipated
• What single technical or compliance constraint would kill the timeline for your preferred go-live date?

Decision economics and acceptance criteria

• If a pilot delivered the target net savings you expect, what would stop you from finalizing a contract that week?
• Which of these financial models do you prefer for alignment, select one? Options: Full rebate pass-through with admin fee, Shared savings model, Spread-based model, Hybrid model
• How do you measure success for a PBM relationship today, pick up to three metrics? Options: Net trend versus baseline, Rebate realization and timeliness, Specialty spend per member, Member access and approval times, Generic dispensing rate
• Describe any performance guarantees or risk-sharing the buyer would require to move forward.
• Which payment timing or reconciliation cadence would you need to see before committing, choose one? Options: Monthly reconciliations with detailed support, Quarterly reconciliations, Annual true-up only, Custom schedule
• What single acceptance criterion would accelerate your sign date if demonstrated in a pilot?

People, timing, and the path to yes

• Who are the essential decision makers and influencers we should engage, list roles rather than names? Options: Benefits director, Chief financial officer, Medical director/clinical lead, Procurement, Benefits consultant
• When do you need a signed contract to meet your fiscal or procurement deadlines? Options: Within 4 weeks, 4–8 weeks, 2–3 months, More than 3 months
• Walk me through the approval steps from pilot success to contract signature, including legal and procurement touchpoints.
• Which members of your team will be available for weekly project calls during a 90-day pilot? Options: Benefits lead, Data analyst, IT/integration lead, Clinical pharmacist, No one available weekly
• What would you consider a realistic go-live window after contract signature given your internal constraints? Options: 30–60 days, 60–90 days, 90–180 days, Longer than 180 days
• Is there any single scheduling or stakeholder conflict that would immediately rule out a near-term pilot?

• Solution Experience: Formulary, Rebate & Specialty Workflows

• Confirm the current state and its cost
• You confirm the current state and the quantified cost of specialty spend, rebate opacity, and formulary disruption.
• Provide the last 12 months of drug spend and rebate reports for analysis.
• You confirm that the demonstrated formulary design and specialty workflow produce the operational improvement you described, with a realistic estimate of trend impact.
• Prove targeted formulary design using your scenario
• Identify 3 high-priority specialty therapy examples and any member disruption cases to use as test scenarios.
• You confirm a preferred rebate pass-through model and the acceptance criteria needed for financial guarantees.
• Run a tailored financial model comparing pass-through, blended, and spread outcomes using the provided data and deliver the results before the follow-up session.
• Demonstrate rebate pass-through options and net impact
• You agree on the remaining evidence, data exchanges, and timeline required to advance to commercial and legal discussions.
• Walk through specialty management and the member journey
• Prepare a draft scope statement that includes proposed formulary tiers, PA/step therapy rules, rebate model options, and specialty pharmacy approach for mutual review.
• Schedule a decision-review meeting with the buying committee and named stakeholders within the agreed timeline.
• Quantify network strategy trade-offs
• Validate that this matches your needs
• Agree next evidence and timeline to decision

• Solution Experience: Formulary, Rebate & Specialty Workflows
• Solution Experience Deck
• Solution Brief — Formulary & Specialty Management

• meeting
• slides
• document

• Manage Clinical Formulary and Tiering
• Administer Real-Time Claims Adjudication
• Enforce Point-of-Sale Clinical Edits and PA Rules
• Operate Prior Authorization and Clinical Review
• Run Step Therapy Enforcement and Exceptions
• Negotiate Manufacturer Rebates and Pass-Through
• Process Rebate Remittance and Reconciliation
• Manage Retail and Mail-Order Pharmacy Networks
• Operate Specialty Pharmacy Dispensing and Fulfillment
• Provide Member Price Transparency Tools
• Deliver Pharmacy Analytics and Reporting Dashboards
• Measure and Report Performance Guarantees

Manage Clinical Formulary and Tiering

• Which formulary tier structure do you want loaded for your plan (choose the closest)? Options: 2-tier (Preferred/Non-preferred), 3-tier (Generic/Preferred/Non-preferred), 4-tier (Generic/Preferred/Non-preferred/Specialty), 5-tier or custom tiering
• How many National Drug Code (NDC) or GPI line items will your initial formulary load contain? Options: Fewer than 5,000, 5,000-25,000, 25,000-100,000, More than 100,000
• Provide the file format and sample filename for your formulary load (for example formulary_load.csv or formulary_load.xml) and any required field names. Options: CSV, XML, JSON, Other (explain)
• List any therapy classes or specific molecules that must be excluded or placed on a medical-only or prior-authorization-only list in your formulary.
• Identify the clinical reference sources you require the formulary to align with (for example FDA label, National Drug Codes (NDC) mapping, specialty clinical guideline citations). Options: FDA label, Therapeutic class guideline (specify), Custom clinical criteria (upload), Other
• Who in your organization will be the approver for formulary changes and what is their title and contact method?

Administer Real-Time Claims Adjudication

• Which claim transaction standards and endpoints must we support for your real-time point-of-sale adjudication (for example NCPDP 5.1 or NCPDP Telecommunication vD.0)? Options: NCPDP 5.1, NCPDP Telecommunication vD.0, Proprietary switch (provide spec), Other
• How many active BIN/PCN/FACILITY combinations does your current routing require for pharmacy network settlement? Options: 1-5, 6-20, 21-100, More than 100
• Describe any adjudication latency or availability SLAs required for point-of-sale responses (for example 250 ms median authorization response, 99.9% uptime).
• Which eligibility and enrollment feeds must the adjudication engine consume at go-live (for example 834 enrollment feed, daily roster CSV, API eligibility endpoint)? Options: 834 EDI file, Daily CSV roster, API eligibility endpoint (specify), No automated feed
• List any claim-level edits or custom pricing algorithms to apply during adjudication (for example MAC lists, adjudicated copay override rules, special rebate-offset pricing).
• Do you require test-case scenarios and pass/fail acceptance for real-time adjudication (for example test card BIN, test member IDs, and expected pay/cost-share)? Options: Yes, require test-case matrix and sample claims, No, limited testing only, Require discussion

Enforce Point-of-Sale Clinical Edits and PA Rules

• Which clinical edits must be enforced at point-of-sale (for example drug-drug interaction severity threshold, therapeutic duplication checks, age/gender contraindication rules)? Options: Drug-drug interactions, Therapeutic duplication, Age/gender contraindications, Other (specify)
• How will you supply the initial prior authorization (PA) rule logic for point-of-sale enforcement (for example ePA XML, spreadsheet of clinical criteria, or manual specification)? Options: ePA XML or standard format, Spreadsheet of criteria, Manual specification during kickoff, Other
• Specify any reject codes or DUR (Drug Utilization Review) messages that must be translated into member-facing SMS or pharmacy-facing messages at the POS.
• Which pharmacies or pharmacy chains require custom point-of-sale messaging or override privileges based on local contract terms (identify by NPI or chain name if available)?
• State the expected workflow for urgent PA overrides at the counter and the maximum acceptable turnaround time for an override decision. Options: Immediate override at POS, Decision within 1 hour, Decision within 4 hours, Decision within 24 hours
• Do you require audit logs of every clinical edit and PA decision for regulatory or audit purposes (for example time-stamped adjudication logs and decision rationale)? Options: Yes, full audit logs required, No, summary reporting only, Limited logs for escalations

Operate Prior Authorization and Clinical Review

• Which prior authorization channels must be available for prescribers and pharmacies (for example electronic prior authorization ePA via NCPDP SCRIPT, web portal, phone)? Options: ePA (NCPDP SCRIPT), Web portal, Fax/attachment upload, Phone-based review
• How many distinct PA clinical pathways or forms will you require at launch (for example oncology oral agents, high-cost injectables, DME-related meds)? Options: Fewer than 10, 10-25, 26-100, More than 100
• Which clinical guideline documents or prior-auth criteria documents will you provide for reviewer use (for example PDF protocols, ICD-10 crosswalks, therapy step definitions)?
• What service-level targets do you require for PA determination turnaround (for example initial decision within 24 hours for urgent, 72 hours routine)? Options: Urgent within 24 hours; Routine within 72 hours, Urgent within 2 hours; Routine within 24 hours, Custom SLA (specify)
• Who will be the named clinical leads permitted to approve exceptions and what credentials must they have (for example pharmacist reviewer NPI or MD specialty)?
• Describe how PA decisions and clinical rationales must be archived and exported (for example downloadable PDF per case, HL7 CDA export, or database extracts).

Run Step Therapy Enforcement and Exceptions

• Which step therapy protocols must be implemented at launch (identify by therapeutic class or example molecule and the required precursor therapy)?
• How should historical claims be evaluated to determine step therapy compliance (for example lookback window of 180 days against adjudicated 837 claims)? Options: 90 days, 180 days, 365 days, Custom lookback (specify)
• What exception reasons should be allowed for step therapy (for example intolerance, clinical contraindication, previous failure) and what documentation will you accept? Options: Intolerance with documentation, Clinical contraindication note, Prior failure with chart note, Other (specify)
• Which systems must receive step-therapy exception results (for example EHR via API, prescriber portal, pharmacy POS messaging)? Options: EHR API, Prescriber portal, Pharmacy POS, Email notification
• Who is authorized in your organization to approve durable step-therapy exceptions and what sign-off artifact is required (for example clinician-signed form, EHR note)?
• Do you require a retrospective monitoring report on step-therapy bypass frequency and prescribing patterns (for example monthly exceptions rate by prescriber)? Options: Yes, monthly reporting, Quarterly reporting, No retrospective reporting

Negotiate Manufacturer Rebates and Pass-Through

• Which rebate models are you considering for this engagement (select all that reflect your preference)? Options: Full pass-through with admin fee, Net price guarantee with reconciliation, Traditional spread model, Hybrid model
• How do you prefer manufacturer remittance to be evidenced at reconciliation (for example invoice with product-level remittance, ERA-style EDI, or contractual schedule)? Options: Manufacturer invoice, EDI remittance file (specify format), Contract schedule, Other
• Identify the contract clauses or rebate categories that must be preserved during negotiation (for example clinical performance rebates, market-share-based rebates, enrollment-based rebates).
• Which functional owner in your organization will review and approve rebate schedules and pass-through mapping (title and preferred contact)?
• What acceptance criteria will confirm rebate pass-through is implemented correctly (for example sample remittance showing product-level pass-through mapping, month-one reconciliation demonstrating expected dollar flow)?

Process Rebate Remittance and Reconciliation

• Which remittance file formats must we ingest and reconcile (for example manufacturer CSV remittance, ERA/EDI 820/835, or vendor portal reports)? Options: CSV invoice, ERA/EDI 820 or 835, Vendor portal export, Other
• How frequently do you require rebate reconciliation and posting (for example monthly, quarterly, or per remittance)? Options: Monthly, Quarterly, Per remittance, Other (specify)
• Describe the tolerance thresholds for reconciliation variances that trigger investigation (for example discrepancies greater than 2% or $5,000).
• Which accounting codes or GL mappings must rebate remittances post to in your ledger (provide GL segments or chart of accounts guidance)?
• What format do you require for reconciliation deliverables (for example PDF executive summary plus line-item CSV with NDC-level detail)? Options: PDF summary + CSV detail, Dashboard only, Custom report format (specify)
• What evidence will validate successful reconciliation and posting to your finance systems (for example matched ERA, reconciled CSV, and confirmation of GL entries)?

Manage Retail and Mail-Order Pharmacy Networks

• Which pharmacy chains and independent pharmacies must be in-network at launch and how should they be identified (for example NPI list, chain ID, or ZIP-level coverage)? Options: NPI list upload, Chain ID, ZIP-level coverage, Other
• How should network tiering and preferred pharmacy discounts be reflected at the POS (for example reduced copay at preferred pharmacies, network routing by BIN/PCN)?
• Describe any restricted pharmacy access requirements for controlled substances, specialty meds, or route-of-administration constraints.
• Which mail-order fulfillment rules must be applied (for example days-supply limits, split-fill allowances, home-delivery waiver)? Options: 90-day fill allowed, Split-fill allowed, Home-delivery only for maintenance meds, Other
• Who will provide pharmacy contract rate files or DIR (Direct and Indirect Remuneration) adjustments and in what format?
• Do you require pharmacy onboarding checklists and trading partner agreements for each retail/mail pharmacy (for example EDI trading partner setup, test claims, and certification)? Options: Yes, onboarding required, No, existing setup sufficient, Limited onboarding

Operate Specialty Pharmacy Dispensing and Fulfillment

• Which specialty therapeutic categories or J-codes will be in scope for specialty dispensing at launch (for example oncology injectables, rare disease biologics)?
• How should patient support services be provisioned for specialty drugs (for example cold-chain logistics, nurse educator access, adherence packaging)? Options: Cold-chain logistics, Nurse educator support, Adherence packaging, Other
• What fulfillment SLA do you require for specialty shipments (for example same-day dispatch for urgent, 48-72 hour standard)? Options: Same-day dispatch, 48-72 hours, Custom SLA (specify)
• Which clinical documentation or enrollment forms must be collected before first dispense (for example signed treatment plan, lab results, PDMP check)?
• Identify any state-by-state license or HUB constraints that will affect specialty dispensing and include required NPI or license files.
• Do you require specialty pharmacy integration with your care management system or EHR and which integration surface is preferred (for example HL7, FHIR, API)? Options: HL7, FHIR, REST API, No integration required

Provide Member Price Transparency Tools

• Which member-facing channels must display price transparency (for example web price tool, mobile app, pharmacy POS estimate)? Options: Web price tool, Mobile app, Pharmacy POS estimate, IVR
• What price elements must be shown to members (for example estimated member copay, cash price, rebate-adjusted net cost)? Options: Member copay only, Member copay + cash price, Rebate-adjusted net cost, All of the above
• Which data feeds must the transparency tool consume to display accurate pricing (for example adjudication price APIs, real-time formulary lookups, pharmacy price lists)?
• How should eligibility be validated for price quotes (for example real-time 270/271 eligibility, cached roster, token-based API)? Options: Real-time 270/271, Cached roster, Token API, Other
• Describe any member communication requirements around prior authorization or step-therapy notices that must appear alongside price estimates.
• Do you require anonymized A/B testing of different price displays to measure member conversion or adherence impact? Options: Yes, A/B testing required, No, not required, Maybe, discuss

Deliver Pharmacy Analytics and Reporting Dashboards

• Which key performance indicators must appear on your executive dashboard at launch (for example trend PMPM, rebate realization %, generic dispensing rate)? Options: Trend PMPM, Rebate realization %, Generic dispensing rate, Custom KPI (specify)

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Pricing and Order Form
• Rebate Pass-Through and Reconciliation Agreement
• Rebate Audit and Reconciliation Rights
• Performance Guarantee Addendum
• Data Processing Agreement (DPA)
• HIPAA Business Associate Addendum (BAA)
• Acceptance Criteria and Go-Live Certificate
• Data Sharing and Analytics Agreement
• Confidentiality Agreement (NDA)

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate, Outcome Validation and Sign-off (around day 90)
• Quarterly Success Review
• Annual Realization Review

• Publish the quarterly outcome dashboard with reconciled data and the current issue burn-down list.
• Publish the acceptance decision record with evidence packs and signatory details, and circulate the remediation plan for any failed items.
• Execute the incumbent wind-down tasks and deliver proof of contract termination or read-only status and data archive completion.
• Schedule the first ongoing quarterly success review and confirm the dashboard deliverables required for ongoing tracking.
• Quarterly outcome trend review
• Verify whether specialty spend and network access metrics are tracking to the targets recorded in Outcome Discovery and document any corrective actions.
• Ensure all high-priority operational issues have owners and firm remediation dates.
• Prioritize enhancement requests for the next quarter with agreed owners and delivery windows.
• Re-confirm success criteria and named owners
• Deliver prioritized enhancement request summaries with proposed acceptance criteria and target delivery quarter.
• Complete assigned operational remediation tasks and report closure evidence before the next quarterly review.
• Annual outcome reconciliation
• Produce a documented annual realization record that reconciles pharmacy trend and rebate performance to the commitments recorded in Outcome Discovery.
• Agree timelines to close any remaining high-impact operational issues and confirm owners for each item.
• Confirm the measurement plan and dashboarding requirements for the next 12 months.
• Publish the annual realization record including reconciled metrics, data sources, and narrative of major drivers.
• Deliver a schedule for closing the high-priority backlog items with target completion dates and acceptance criteria.
• Provide the agreed dashboard and data export specification that will be used for next-year quarterly and annual reviews.
• Confirm all critical integrations and data feeds are functional or have concrete remediation plans.
• Document and assign owners and target dates for all high-priority blockers.
• Ensure the buyer has access and basic workflows are operating to allow the first measurable period.
• Publish the deployment validation checklist with itemized owners and target close dates.
• Run agreed test cases for any remediated integrations and report results within the agreed remediation window.
• Share initial usage log extracts to validate adoption signals for the first measurement meeting.
• Present first-period outcomes versus targets
• Confirm whether early trend and rebate metrics are on track to meet targets recorded in Outcome Discovery and document any shortfalls.
• Assign corrective actions with owners and firm completion dates to address identified root causes.
• Agree a timeline to the acceptance gate meeting and required data deliverables for that gate.
• Deliver a side-by-side data pack showing the measured metrics versus targets recorded in Outcome Discovery, including supporting drill-downs for specialty spend drivers.
• Execute assigned remediation tasks and provide interim status updates weekly until closed.
• Confirm the dataset and cadence that will be used for the acceptance gate review.
• Restate numeric acceptance criteria
• Produce a documented acceptance decision for each numeric criterion recorded in Outcome Discovery and capture the buyer's named signatory where required by the engagement.
• If any criterion failed, agree a concrete remediation plan with dates and a retest schedule.
• Confirm the incumbent has been decommissioned or is formally retained read-only and that data migration or archiving is complete where applicable.
• Open issue burn-down and service-level review
• Specialty spend and member access summary
• Present outcome data against each criterion
• Root-cause diagnosis for any gaps
• Deployment and integration validation
• Enhancement and change request triage
• Document pass/fail per criterion and capture acceptance decision
• Outstanding issues and enhancement backlog review
• Operational health and member impact review
• Early adoption signals and usage patterns
• Document annual realization and next-year measurement plan
• Blockers and open issues with owners
• Agree corrective actions and timelines
• Short operational actions and next steps
• Remediation plan for any unmet criteria
• Immediate remediation actions and short-term checklist
• Incumbent wind-down confirmation