Quick hello: who are we speaking with today?

• Which of these best describes your role for pharmacy benefit decisions? Options: CFO / Finance leader, Director of Benefits / Total Rewards, Procurement lead, HR leader, Benefits consultant/advisor, Other (please specify)
• How many covered lives does this plan represent today? Options: 5,000–9,999, 10,000–24,999, 25,000–49,999, 50,000+
• When does your current PBM contract expire (month/year)?
• Who recommended or helped select your current PBM? Options: Independent consultant (no PBM ties), Benefits consultant with PBM relationships, Broker or aggregator, Procurement team, Internal decision, Other
• If there’s one thing you want us to know about your situation before we dig in, what is it?

Are you okay letting a three-year PBM contract quietly cost you millions?

• How confident are you that your current PBM reports capture all rebate retention and spread accurately? Options: Very confident, Somewhat confident, Not confident, We don’t know—reporting is unclear
• Tell us about the last time pharmacy costs surprised you—what happened and how did it feel to the finance team?
• Have you seen NDC-level claims and pricing detail for the period driving the renewal increase? Options: Yes—full NDC-level datasets, Partial NDC detail (some fields missing), No—we only get summary reports, PBM says they can’t or won’t provide it
• Which internal teams get pulled into investigating a pharmacy spike? (select all that apply) Options: Finance, Benefits/HR, Medical/Pharmacy clinical team, Legal, Procurement, Executive leadership
• How does the leadership team react emotionally when a renewal projects double-digit increases—panic, pressure to act quickly, or cautious analysis? Options: Panic/urgent action, Pressure to change vendors, Cautious—want more data, Defer decision until renewal window

Show us exactly where you think money might be leaking

• Do you have line‑level visibility into rebate schedules, aggregation methods, and pass‑through terms today? Options: Yes—rebate schedules and pass‑through are transparent, Partially—some contract clauses are unclear, No—rebate treatment is opaque
• Which of these contract primitives do you believe are most likely to be costing you money right now? Options: Rebate aggregation/retention clauses, Spread pricing on generics, MAC list manipulation, Specialty carve‑in/out discrepancies, Incorrect GPO pass‑throughs, Other
• Do you have access to PBM claim line fields we’d need for an NDC-level audit (NDC, ingredient cost, dispensing fee, NABP, prescriber, date of service)? Options: Full file with all fields, File with some fields missing, Only summarized reports, Not provided
• If you had to estimate, what dollar range of potential overpayment would make you pursue a full audit? Options: <$250k, $250k–$1M, $1M–$5M, >$5M, Not sure yet
• Describe any past findings from audits or vendor reviews—what did you find, who reacted, and what changed?

If we could show you NDC‑level proof of millions saved, what would you actually do with it?

• What minimum level of projected annual savings would justify a vendor change or aggressive renegotiation for your team? Options: <$250k, $250k–$1M, $1M–$5M, >$5M, We need percentage impact vs. budget
• Would dollar-level NDC evidence need CFO sign‑off, board approval, or is benefits/procurement empowered to act? Options: Benefits/procurement can act, CFO approval required, Executive/Board approval required, Depends on savings size
• If savings are primarily from therapeutic substitution or 340B optimization, how open is clinical leadership to implementing those changes? Options: Very open—clinical partner involved, Somewhat open—needs evidence, Resistant—clinical concerns likely, Unknown
• How specific must our recommendations be for you to accept them (e.g., product-level NDC swap with projected $ per member per year vs. high-level categories)? Options: NDC-level dollar projections, Drug-class level with examples, Percent-based savings only, Must include operational implementation plan
• Imagine the audit shows issues with rebate pass‑through—what outcome would you consider a success (recover funds, renegotiate, terminate)? Options: Recover back payments, Renegotiate terms, Switch PBMs at renewal, Change advisor/consultant, Other

Who really signs the check and who will push back?

• List the decision‑makers who must approve a PBM retainer or contract change and their typical priorities (finance, clinical, procurement, executive):
• Are there external advisors or brokers who must be consulted before decisions—and do they have financial ties to PBMs? Options: Yes, tied to PBMs, Yes, independent, No external advisors involved, Not sure
• How important is a signed independence disclosure from your advisor when selecting an auditor? Options: Critically important, Somewhat important, Nice to have, Not important
• What internal approval hurdles have delayed past vendor changes or contract renegotiations? Options: Budget constraints, Leadership resistance, Procurement policies, Legal complexity, Operational risk concerns, Other
• Who will be the day‑to‑day owner for data collection, questions, and signoffs during an audit? Options: Benefits operations, Finance analyst, IT/Data team, External consultant, Other

If the PBM digs in and limits data, what will you do differently?

• Have you experienced PBM resistance to sharing detailed claims or rebate files in the past? Options: Yes—refused full files, Yes—slow to respond, No—PBM cooperative, We haven’t asked
• What format do your available files arrive in today (select all that apply)? Options: Flat CSV/pipe-delimited claims export, Encounter files (standardized), Rebate schedules (PDF/Excel), MAC logs (Excel/PDF), API access, We don’t have files
• Which internal systems or teams will need to be involved to map and ingest PBM data (HRIS, Data Warehouse, IT security)? Options: IT/data warehouse, Benefits operations, Security/compliance, External advisor, None—outsourced
• Do you have legal or contractual constraints that limit sharing NDC‑level claims externally? Options: Yes—data sharing restrictions exist, No restrictions, Under review/need approvals, Not sure
• Describe any previous attempts to reconcile rebates, MAC, or spread issues—what data was missing and who owned the follow‑up?

How will you judge whether our audit is credible and defensible?

• Which teams must sign off on our final acceptance checklist (Finance, Clinical, Legal, Procurement)? Options: Finance, Clinical/Pharmacy, Legal, Procurement, Executive leadership
• Do you require an independent reconciliation of rebates and savings (e.g., finance-run reconciliation) before changes are implemented? Options: Yes—independent reconciliation required, Prefer reconciliation but can accept combined review, No—platform findings sufficient
• What sample size or time window would satisfy you that findings are valid (e.g., 12 months of claims, rolling 36 months)? Options: 12 months, 24 months, 36 months, Custom window—please specify
• Which KPIs will determine success after deployment (dollars saved, PMPM reduction, rebate capture %, formulary compliance)? Options: Dollars saved, PMPM reduction, Rebate pass‑through %, NDC-level discrepancies closed, Clinical outcomes preserved
• Who will be the primary contact for disputed contract interpretations if we surface a compliance gap? Options: Benefits director, CFO, Procurement, Legal, External advisor

What keeps you awake at night about doing this audit?

• Which of the following political or operational risks worry you most if audit findings require renegotiation? Options: Damaging relationships with incumbent PBM, Advisor pushback or conflict, Internal resistance to change, Member disruption concerns, Legal exposure
• How tolerant is your leadership for public confrontation with an incumbent vendor versus quietly negotiating fixes? Options: Prefer public/firm stance, Prefer private renegotiation, Prefer to avoid conflict if possible, Undecided
• If a findings report triggers a formal dispute, who leads the response and what timeline would you expect? Options: Legal—immediate, Procurement—30–60 days, Executive—as needed, We don’t have a plan
• Share a specific internal political hurdle you’ve faced on benefits projects—what happened and how was it resolved?

If we commit to a short pilot, what would make us an easy yes?

• How soon would you be willing to provide test claims data for a pilot analysis (assuming NDAs and security controls are in place)? Options: Immediately, Within 2 weeks, Within 1 month, Longer—need approvals
• What budget or retainer range are you comfortable allocating to independent PBM audit and renewal support? Options: <$25k, $25k–$50k, $50k–$100k, >$100k, Undecided/need proposal
• Which SLA elements matter most for you during the renewal window (data turnaround time, findings cadence, dispute response time)? Options: Data turnaround time, Weekly progress reporting, Dedicated account team, Fast dispute response
• What would be an acceptable timeline from pilot to a board‑ready findings report? Options: 4–6 weeks, 6–8 weeks, 8–12 weeks, Longer—complex case
• If we ask for a signed independence disclosure and data access authorization, who in your organization needs to sign? Options: CFO, Director of Benefits, General Counsel, Procurement, Other

Starting the Conversation: Where are you right now?

• Tell us the size of the self-funded population you're responsible for (covered lives). Options: 5,000–9,999, 10,000–24,999, 25,000–49,999, 50,000+, Prefer not to say
• When does your current PBM contract expire (or next renewal window)? Options: <6 months, 6–12 months, 12–18 months, 18–24 months, 24+ months, Unsure
• Briefly describe the immediate trigger for this review (e.g., renewal increase, specialty spend spike, consultant recommendation).
• What percentage increase did your pharmacy spend show in the most recent renewal notice (approx)? Options: <5%, 5–10%, 10–15%, 15–25%, >25%, Unsure
• Who will be the primary day-to-day contact for this discovery (name/role)?
• Who are the core decision-makers for PBM renewal (select all that apply)? Options: CFO, Director of Benefits/HR, Procurement, General Counsel, Finance Lead, Benefits Consultant/Advisor, Other

Are You Being Told the Whole Story?

• What would it mean to your organization if the PBM's reporting omitted millions in retained rebates or spread?
• Which of the following have you seen in your PBM reports that feel incomplete or unclear? Options: Aggregate rebate totals only, No NDC-level pass-through detail, Bundled administrative fees, Unclear spread calculations, Missing MAC audit trails, Other
• Have you requested NDC-level rebate and pricing detail from your PBM before? If yes, what happened? Options: Requested and received full detail, Requested and received partial detail, Requested and denied access, Never requested, Other (explain)
• How confident are you that the PBM’s claims reporting can be reconciled to your finance systems at the dollar level? Options: Very confident, Somewhat confident, Not confident, Don't know
• Describe a specific example when PBM reporting left you frustrated or forced a difficult decision.
• Who on your team currently validates PBM reports and how do they escalate concerns? Options: Finance (internal), Benefits/HR team, External advisor, No one regularly validates, Other

Who’s Steering the Ship — and Who Might Have Conflicted Ties?

• If one of your advisors has a referral relationship with the PBM, how would that change your trust in their recommendations? Options: I'd be very concerned, I'd want full disclosure then evaluate, It wouldn't change my trust, Unsure
• Which external advisors are currently involved in your PBM strategy or renewal? (select all that apply) Options: Benefits Consultant (independent), Benefits Consultant (PBM-affiliated), Broker, Actuarial firm, Legal counsel, No external advisors, Other
• Do you have signed disclosure statements confirming advisors' financial relationships with PBMs, manufacturers, or specialty pharmacies? Options: Yes — all advisors disclosed and signed, Some advisors disclosed but no signed form, No disclosures collected, Not sure
• Who on your side would need to sign an independence/zero-relationship disclosure from an advisor or vendor? Options: CFO, Director of Benefits, Procurement, Legal, Other
• How would you feel if a recommended advisor refused to sign a disclosure stating zero financial ties to PBMs? Options: Terminate relationship immediately, Require more transparency before proceeding, Accept with caveats, Not sure
• Tell us about any past situations where vendor or advisor conflicts affected outcomes (what happened, and what did you learn?).

What Does ‘Meaningful Savings’ Look Like for You?

• Would a category-level savings estimate be sufficient for your CFO, or does the savings case need NDC-level, dollar-specific line items? Options: NDC-level dollar detail required, Category-level with examples is acceptable, Either is fine, Unsure
• What minimum annual savings (net of fees) would justify a change or aggressive negotiation with your PBM? Options: <$100k, $100k–$500k, $500k–$1M, $1M–$5M, >$5M, Unsure
• Which of these NDC-level opportunities would your team consider actioning if proven (select all that apply)? Options: Therapeutic substitution, Biosimilar conversion, Specialty site-of-care shift, 340B carve-in optimization, MAC pricing enforcement, Other
• How important is clinical team buy-in (pharmacy medical director, PBM pharmacist, or internal clinicians) to approving NDC-level recommendations? Options: Critical — must sign off, Important but not mandatory, Nice to have, Not necessary
• What level of confidence do you require on projected savings (e.g., 90% certain, range, or conservative estimate)? Options: High confidence (≥90%), Moderate (70–90%), Range estimate acceptable, Prefer conservative floor only, Unsure
• Share an example of a savings claim from a vendor or advisor that felt overpromised—what was missing?

Data & Access: If You Can’t Get the Files, Nothing Else Matters

• If the PBM resists providing full NDC-level claims and rebate detail, what are you willing to do to secure it? Options: Escalate to PBM account team, Use contractual leverage, Initiate procurement/legal action, Walk away from audit, Other
• Which of these datasets can you already share quickly (select all that apply)? Options: PBM claims export (NDC-level), Encounter files, Rebate schedules, MAC logs, Drug pricing files, None available right away, Other
• How long will it realistically take to obtain necessary legal approvals (DUA, BAAs, counsel sign-off) to share NDC-level data? Options: <2 weeks, 2–4 weeks, 1–2 months, 2–3 months, >3 months, Unsure
• Have you experienced PBM delays or pushback on providing data in the past? Describe the impediment.
• Would you be open to a phased data approach (sample months or a de-identified subset) to validate capability before full ingestion? Options: Yes — phased approach preferred, Maybe — depends on sample, No — need full dataset up front, Unsure
• Which internal owner will be responsible for shepherding data requests with the PBM? Options: Benefits lead, Finance/FP&A, Procurement, IT/Security, External advisor, Other

When Findings Force Hard Conversations, Are You Ready?

• If an audit shows your PBM missed guarantees or retained rebates improperly, how willing are you to escalate to contract renegotiation or termination? Options: Very willing, Somewhat willing, Prefer to negotiate quietly, Unwilling, Unsure
• Who would lead the governance and dispute process (roles and escalation path)?
• Do you have budget or executive support for an advisory retainer to cover detailed NDC-level audit work during the renewal window? Options: Yes — budget approved, Budget likely but not approved, No budget currently, Unsure
• Which outcomes would justify paying an advisory retainer (select all that apply)? Options: Clear dollar recovery, Contract compliance documentation, Stronger negotiating leverage, Ongoing monitoring, Internal audit evidence, Other
• If a dispute arises, how important is having an independent, signed disclosure of advisor independence to support your position? Options: Essential, Important, Nice to have, Not necessary
• Describe the most important non-financial outcome you’d need from an audit (e.g., transparency, vendor accountability, policy change).

What Would Full Transparency and Success Enable?

• Imagine you finish renewal with NDC-level clarity and confirmed rebate pass-through—what decisions become possible that weren’t before?
• Which KPIs would you use to judge this engagement’s success at 6 and 12 months (select all that apply)? Options: Realized $ savings, Rebate pass-through accuracy, MAC guarantee compliance, Reduction in specialty spend trend, Speed of PBM cooperation, Internal stakeholder satisfaction
• How quickly do you need initial audit findings to inform negotiation strategy (timeline)? Options: <2 weeks, 2–4 weeks, 1–2 months, 2+ months, No timeline
• What reporting format will finance and clinical teams require to sign off on recommendations (NDC-level spreadsheets, executive summary, reconciliation worksheets)? Options: NDC-level spreadsheets + reconciliation, Executive summary only, Interactive dashboards, Both spreadsheets and dashboard, Unsure
• If we identified actionable savings, what internal approvals are required to implement changes (roles and signoff thresholds)?

Next Steps: How Do You Want Us to Partner?

• Would you prefer we start with a short proof-of-value (sample months) or a full NDC-level ingestion up front? Options: Proof-of-value sample first, Full ingestion up front, Unsure — discuss options, Other
• What level of interaction do you want during discovery (weekly checkpoints, biweekly updates, as-needed) Options: Weekly, Biweekly, Monthly, As-needed
• Who needs to be included in our next meeting (roles and names)?
• What would make you comfortable signing an independence disclosure from us (elements or assurances we should include)?
• Realistically, when could you commit to providing a sample dataset or approvals to begin work? Options: Immediately, Within 2 weeks, 2–6 weeks, 6–12 weeks, Longer/Unsure
• Is there anything else we haven’t asked that would change how you approach a PBM audit or vendor selection right now?

Getting Comfortable Together

• Who are you and which roles will you personally represent in the pharmacy renewal process? Options: CFO, Director of Benefits, Head of Procurement, Head of Finance, General Counsel, Benefits Consultant, HR Leader, Other — please specify
• When does the incumbent PBM contract expire (or when is your renewal window starting)? Options: <6 months, 6–12 months, 12–18 months, 18+ months, Not sure / need to check
• How many covered lives does this plan include today? Options: 5,000–9,999, 10,000–24,999, 25,000–49,999, 50,000+, Unsure / need to confirm
• How has total pharmacy spend changed over the last 12 months (approx.)? Options: Declined, Flat (±2%), Up 3–9%, Up 10–20%, Up >20%, Not certain
• What are your immediate feelings about the upcoming renewal—confident, anxious, resigned, curious, or something else? Options: Confident, Anxious, Resigned, Curious, Frustrated, Other — describe
• Who on your team will be the day-to-day contact for data and scheduling?

If Your PBM Numbers Are Wrong, How Fast Would You Feel the Pain?

• If your PBM's reporting understated overpayments by 20% next year, what would that mean to your budget or renewal strategy?
• Which part of PBM reporting makes you most suspicious: rebate pass-through, spread pricing, MAC compliance, or rebate allocation? Options: Rebate pass-through, Spread pricing, MAC compliance, Rebate allocation / aggregation, Other — please specify
• Have you ever commissioned an independent NDC-level audit before? If yes, what did you find and how was it handled? Options: No, never, Yes — findings corrected and recovered, Yes — findings disputed and unresolved, Yes — minor issues only, Other — describe
• How comfortable are finance and clinical leaders with the level of detail in current PBM reporting (NDC-level vs. category-level)? Options: Comfortable with NDC-level, Comfortable with category-level only, Need NDC-level but don’t have it, Unaware of the difference
• What specific story or evidence would convince you that a PBM is retaining plan money rather than passing it through?
• Who on your side would need to approve running a historical claims sample through an independent platform? Options: CFO, Director of Benefits, Procurement, Legal, IT/Security, Other — list names/roles

Where the Money Might Be Hiding

• How certain are you that rebates and spread are being passed through at competitive rates? Options: Very certain, Somewhat certain, Unsure, I suspect underpassage but need proof, I expect significant retention
• Which therapeutic areas or drugs are driving the recent spike in costs for you? Options: Specialty biologics, Newest specialty launches, High-cost generics, Biosimilars, Site-of-care issues, 340B-related claims, Other — specify
• Estimate the dollar range you believe could be at risk from poor pass-through or spread over a three-year contract. Options: <$100k, $100k–$500k, $500k–$1M, $1M–$5M, >$5M, Don't know
• Have you observed unexplained variances between PBM rebate schedules and actual remittances to the plan (e.g., timing, aggregation differences)? Options: Yes — significant variance, Yes — minor variance, No variance observed, Haven't reviewed rebate schedules in detail
• How would discovering material overpayment change your approach to advisor relationships or procurement strategy?
• Which outcomes would you prioritize if we found leakage—recover dollars, renegotiate contract terms, change PBM, or public disclosure? Options: Recover dollars, Renegotiate terms, Change PBM at renewal, Escalate with advisor/board, Other — describe

The Truth About Your Data

• If we asked the PBM for NDC-level claims exports, encounter files, rebate schedules, and MAC logs tomorrow, what would they likely provide? Options: All immediately and fully, Most with minor delays, Partial sets or aggregated only, Refuse or require contract amendment, Not sure
• Which of the following data items do you already have or can compel for analysis? Options: PBM claims export (NDC-level), Encounter files, Rebate schedules / reconciliation files, MAC logs and appeal records, Formulary and clinical edit rules, None of the above
• What file formats and transfer methods are available from your vendors (select all that apply)? Options: Flat files (CSV/TSV), Fixed-width exports, EDI 837/835, SFTP / Secure API, Vendor portal download only, Other — describe
• Do you have signed legal permissions and data-use agreements in place to allow an independent audit of identifiable claims at the NDC level? Options: Yes — ready, Yes — need amendments, No — legal must draft, Unsure / need to check
• Who owns the data handoff internally (name/role), and how quickly can they onboard secure access?
• What privacy or security constraints would we need to honor (PHI redaction, SOC2 vendor requirements, encrypted SFTP, etc.)? Options: PHI allowed under BAA, Only de-identified data, Strict vendor security review required, No special constraints, Other — specify
• Have you previously requested MAC logs or rebate detail from the PBM, and if so, what was the response? Options: Provided promptly, Provided partially, Denied / delayed, Never requested

Who Needs to Be in the Room — Really

• If you could pick the three people whose buy-in matters most for a successful audit and recovery, who would they be and why?
• Which of the following stakeholders will influence the renewal decision and must sign off on findings? Options: CFO, Director of Benefits, Procurement, Legal / GC, Actuary, Benefits Consultant / Advisor, Board / Trustees, Other — list
• Do you have an advisor or consultant with a referral/financial relationship to the incumbent PBM that we should be aware of? Options: Yes — disclosed relationship, Yes — undisclosed / unsure, No such relationship, Prefer not to say
• Who on your team typically approves retainers or advisory spend for renewal work (role/title)? Options: CFO, VP Finance, Director of Benefits, Procurement, Board/Committee
• What internal approval hurdles or procurement rules could delay starting an audit (e.g., RFP required, legal review cycles)? Options: RFP required, Legal must approve, Board approval required, Budget cycle timing, None / can start quickly, Other — describe
• How does knowledge of a benefits consultant’s PBM tie-in change your willingness to act on audit findings? Options: Makes us more likely to audit, No change, Creates political resistance, Unsure

What Success Actually Looks Like (Dollar-level, Not Buzzwords)

• What is the minimum dollar impact that would make an audit and potential renegotiation worthwhile to you? Options: <$100k, $100k–$500k, $500k–$1M, $1M–$5M, >$5M, Unsure / want an assessment
• Which acceptance criteria would your finance team require to sign off on audit results? Options: NDC-level accuracy, Rebate remittance reconciliation, MAC guarantee validation, Independent statistical sampling, Audit trail and reproduceable methods, Other — specify
• Over what timeframe would you expect recovered or avoided spend to be realized (select all that apply)? Options: Immediately (retro recovery), Within 6 months, 6–12 months, Within next contract year, Over the full contract term, Unsure
• Would you consider a pilot focused on a high-risk NDC cohort before a full audit? If so, which cohort would you prefer? Options: Top specialty spenders, High-volume generics, Recent specialty launches, 340B-impacted claims, Random sample of claims, No pilot — full audit only
• Which commercial models would you find acceptable for advisory/tech work (select all that apply)? Options: Fixed retainer, Hourly advisory, Success fee on recovered dollars, Blended retainer + success fee, Project-based fixed fee, Other — propose
• Who must endorse the final acceptance (e.g., CFO sign-off, clinical lead sign-off, procurement approval)? Options: CFO, Director of Benefits, Finance Controller, Clinical Director / Medical Review, Procurement, Other — list

Barriers, Politics, and the Quiet Resistance

• Who inside or outside your organization could quietly block or slow a PBM audit if results threaten trusted relationships? Options: Benefits consultant/advisor, Procurement comfortable with current vendor, Legal concerned about disputes, Executive leadership worried about disruption, PBM pushback, Other — specify
• Have you experienced pushback from your PBM when asking for granular data or reconciliation in the past? Options: Yes — strong pushback, Yes — minor delays, No pushback, Never asked before
• If the PBM disputes an audit finding, how would you prefer to handle it: mediation, escalation to counsel, leverage benchmarking, or publicly disclose? Options: Mediation, Involve counsel, Use benchmark comparisons, Escalate to board, Public disclosure / stakeholder alert, Other — describe
• Would internal politics make it harder to recover funds even if we proved overpayment? Options: Yes — significant risk, Some risk, Unlikely, No
• What communications or governance structures would make leadership more comfortable with audit findings being acted upon? Options: Executive summary to board, Joint PBM meeting, Legal sign-off on findings, Third-party validation, Other — specify
• Have you defined a dispute governance process for contested contract interpretations today? Options: Yes — formal process, Informal process, No process, Unsure

Next Steps That Don't Waste Time

• If we could surface a credible NDC-level problem within 30 days, what would you want us to deliver first (evidence packet, executive brief, financial model, or remediation roadmap)? Options: Evidence packet with sample claims, Executive one-page brief, Detailed financial reconciliation model, Remediation and negotiation roadmap, All of the above
• How soon could you provide an initial data sample (e.g., 3–6 months of claims) for a fast proof-of-value? Options: Within 1 week, 1–2 weeks, 3–4 weeks, 1–2 months, Longer than 2 months, Unsure
• Which short checklist items must be completed before legal will approve an external audit (BAA, DUA, vendor security review, procurement PO)? Options: BAA/DUA in place, Vendor security review passed, Procurement PO issued, Legal contract amendment, Other — list
• What's your preferred cadence for check-ins during discovery and pilot phases? Options: Weekly, Biweekly, Monthly, Ad-hoc as needed
• Who would be responsible for internal stakeholder briefings when we present preliminary findings? Options: CFO, Director of Benefits, Procurement, Communications lead, Other — specify
• Are you ready to proceed with a scoped pilot if we agree on access and commercial terms today? Options: Yes — ready now, Yes — after legal approvals, Not yet — need internal alignment, No — not interested

Quick Snapshot — A Fast Look at Where You Are

• How many covered lives does this self-funded plan include today? Options: 5,000–9,999, 10,000–24,999, 25,000–49,999, 50,000+
• When is the PBM contract up for renewal (month/year)? Options: Within 6 months, 6–12 months, 12–18 months, 18+ months, Unsure
• Who recommended your current PBM and what relationship, if any, do they have with that PBM? Options: Benefits consultant/advisor (no disclosed relationship), Benefits consultant/advisor (has referral/financial relationship), Procurement, Internal team selected, Other
• Roughly how much did pharmacy spend change year-over-year most recently (percentage) — pick the closest? Options: Decrease, 0–5%, 6–12%, 13–25%, 25%+
• What would you like us to understand first about your situation (brief summary in your own words)?

Is Your Renewal a Ticking Time Bomb?

• When you look at the renewal window, what's the single biggest risk that keeps you up at night? Options: Unexpected price increases, Hidden spread/rebate retention, Lack of NDC-level visibility, Adviser conflict of interest, Other
• How confident are you that the PBM reporting today shows the true dollars flowing to your plan versus what the PBM retains? Options: Completely confident, Mostly confident, Somewhat skeptical, Not confident at all
• Can you share an example where a monthly or quarterly PBM report felt incomplete or misleading? What specifically raised doubts?
• How often have pricing surprises (rebate shortfalls, spread, MAC issues) required retroactive reconciliation or plan corrections in the past three years? Options: Never, Once, 2–3 times, 4+ times, Unsure
• If your PBM relationship continued as-is for another three years, what financial or operational consequences are you most worried about?

Who Really Holds the Keys? — Mapping Power, Influence & Bias

• Who will sign the PBM contract at renewal and who influences that decision the most? Options: CFO, Director of Benefits, Procurement, Board/Trustees, External advisor/consultant, Other
• How aligned are the CFO, Director of Benefits, procurement, legal, and your benefits advisor on the objectives for pharmacy renewal? Options: Fully aligned, Mostly aligned, Partial alignment, Not aligned, Unsure
• Have any advisors or consultants involved disclosed financial relationships with PBMs, manufacturers, or specialty pharmacies in writing? Options: Yes—signed disclosures on file, Verbal disclosure only, No disclosure provided, Unsure
• Who on your team will be the day-to-day owner for data requests, validation, and governance during an audit? Options: Director of Benefits, HR/Total Rewards, Procurement lead, Finance/Controller, Third-party project manager, Other
• How would you describe internal appetite for taking difficult actions (e.g., pausing payments, demanding reconciliations, or pushing for renegotiation) if audit findings require it? Options: Very high—we will act, Cautiously willing, Reluctant—political constraints, Not willing, Unsure

Tell Me What Data Might Be Missing—But Matters

• If the PBM refused to deliver NDC-level claims or denied access to encounter files, how would that change your confidence in renewal decisions? Options: I’d halt negotiations, I’d proceed with caution, I’d accept higher risk, Unsure
• Which of the following data artifacts can you currently provide or obtain from the PBM within 30 days? Options: NDC-level claims export, Encounter files (medical/pharmacy), Rebate schedules by manufacturer, MAC price logs with timestamps, Clinical prior authorization rules, None of the above
• What formats do you receive claims and contract documents in today (E.g., CSV, EDI, PDF contracts, Excel)? List all that apply. Options: CSV/flat files, EDI 835/837, Excel spreadsheets, PDF contracts/reports, Proprietary portal extracts, Other
• What data gaps have blocked prior reviews from producing actionable NDC-level recommendations?
• Who in your vendor stack will need access to raw data for analysis (internal teams and external partners)? Options: Finance, Clinical/Pharmacy Director, Benefits consultant, Legal, External auditor, Other

What Would NDC-Level Clarity Actually Change for You?

• If you had verified NDC-level pricing and rebate pass-through detail, what decision would you most likely make differently? Options: Renegotiate PBM contract, Switch PBMs, Change formulary/policies, Pursue recoveries/rebates, No change
• What minimum absolute dollar or percentage savings would you need to see at NDC level to justify changing vendors or renegotiating? Options: <$100k, $100k–$500k, $500k–$1M, $1M–$5M, $5M+
• When you review vendor savings pitches, what detail convinces you the number is real: NDC line-items, invoice-level reconciliations, or sample claims walkthroughs? Options: NDC line-items, Invoice-level reconciliations, Representative claims walkthrough, Benchmark comparisons, Other
• How important is clinical validation (e.g., pharmacy director sign-off) versus pure dollar reconciliation for acceptance of an audit finding? Options: Clinical sign-off required, Finance approval sufficient, Both required, Depends on issue
• Describe a decision you would take immediately if we surfaced a recurring generic overpayment or rebate shortfall.

Where Do Contracts Hide Money? — Reading Between the Guarantee Lines

• How confident are you that your PBM contract’s rebate language and MAC guarantees prevent retention of plan dollars? Options: Very confident, Somewhat confident, Not confident, We haven’t reviewed closely
• Have you ever disputed a PBM interpretation of a contract guarantee? What was the outcome? Options: Yes—successfully recovered, Yes—partial recovery, Yes—no recovery, Never disputed, Prefer not to say
• Which contractual elements matter most to you to verify during an audit? Options: Rebate pass-through definition, Spread pricing clauses, MAC price floors/guarantees, Rebate aggregation/assignment clauses, Appeal timelines, Other
• Can you upload or point to a redacted copy of the current PBM contract and exhibit(s) that define rebates and reconciliation rules? Options: Yes—full contract available, Yes—but redaction required, No—not accessible, In process
• How long have you been operating under the current contract terms, and have those terms materially changed in that period? Options: <1 year, 1–3 years, 3–5 years, 5+ years

How Ready Is Your Team to Act on Hard Findings?

• If an audit finds multi-million-dollar discrepancies, who on your team has authority to demand immediate remedial action (e.g., hold payments, seek clawbacks)? Options: CFO, Director of Benefits, Procurement, Board/Trustees, Requires legal sign-off, Other
• What internal blockers (political, contractual, vendor relationships) are most likely to slow or stop follow-through after findings? Options: Advisor loyalty, Vendor retaliation risk, Procurement timelines, Board resistance, Legal ambiguity, Other
• How quickly could your team convene a cross-functional governance group (Finance, Clinical, Legal, Procurement) to review audit findings? Options: Within 1 week, 2–4 weeks, 1–3 months, Longer than 3 months, Unsure
• What training or handoffs would help your staff act confidently on contract compliance issues surfaced by an NDC-level audit? Options: Hands-on claims walkthroughs, Executive summary + remediation playbook, Legal workshops, Ongoing dashboard access, Other
• Who on your team should we include in technical onboarding and who should be the executive sponsor?

What Would Success Look Like—and How Will You Know?

• Beyond dollars saved, what outcomes would make you call this engagement a clear success? Options: Transparent reporting, Contractual remediation, Improved formulary adherence, Operational ownership transfer, Stronger governance
• Which single metric will your CFO insist on seeing to approve a recommendation (e.g., net savings, rebate reconciliation, ROI over contract term)? Options: Net annual savings, Total recoveries/repayments, ROI within 12 months, Reduction in per-member-per-month (PMPM), Improved rebate pass-through %
• What acceptance criteria (financial thresholds, reconciliation accuracy, clinical sign-off) must be met before your team considers a recommendation actionable?
• How often would you want to see progress reports during deployment and after go-live (cadence)? Options: Weekly, Bi-weekly, Monthly, Quarterly, Ad-hoc as issues arise
• Who needs to sign off on final acceptance of audit outputs (finance, clinical, legal)? Please list roles.

If We Move Forward, What Could Stop It?

• What’s the most likely single thing that would derail a data-driven audit before it begins? Options: PBM refuses data access, Advisor opposition, Board blocks budget, Legal concerns, Internal resource constraints
• Have you experienced pushback from a PBM during a previous data request or audit? What form did it take (delays, partial extracts, legal threats)? Options: Delays, Partial extracts, Legal pushback, No pushback, Other
• What contractual or legal protections would make you comfortable proceeding even if a PBM resists (e.g., audit clauses, holdbacks, escrow)?
• If we surfaced material non-compliance, how much internal political capital would you be willing to invest to pursue remediation? Options: Very high, Moderate, Low, None, Unsure
• Are there external dependencies (broker approvals, board cycles, union negotiations) that could block timely decisions? Please specify.

Next Steps & Signals — What Would Make This Real?

• If we proposed a representative pilot using a 12–24 month claims window, how likely are you to authorize it given current circumstances? Options: Very likely, Somewhat likely, Unlikely, Need more info
• What internal approvals are required to engage an independent audit and who must sign the statement of work?
• Do you have a budget range or retainer tolerance for renewal-window advisory work? Options: <$50k, $50k–$150k, $150k–$350k, $350k+, Unsure
• What would you need from us to present this engagement to your executive team with confidence (one-pager, sample findings, references, redacted case studies)? Options: Executive one-pager, Representative claims walkthrough, Redacted case study, References from similar employers, All of the above
• Who should we schedule a technical kickoff with if you decide to proceed (include name, role, and email if possible)?

Starting Point: Who's Actually in the Room?

• Who from your team will own the PBM renewal and be active in this discovery? Options: CFO, Director of Benefits, Procurement Lead, HR/Total Rewards, In-house Counsel, External Benefits Consultant, Other
• What’s your current PBM contract end date (month/year)?
• How many months before renewal do you want final recommendations in hand? Options: 18+ months, 12–18 months, 6–12 months, Under 6 months, Unsure
• Which decision criteria will matter most when choosing next steps (select top 3)? Options: Documented dollar savings, NDC-level auditability, Vendor independence / no conflicts, Speed to implementation, Ongoing monitoring capability, Minimal operational disruption, Price transparency
• What outcome would make your CFO say “this discovery was worth it” (be specific, $ targets or governance changes preferred)?

If Your PBM Report Was a Financial Statement, Would You Sign It?

• If I asked your CFO to explain exactly how rebates were applied last quarter, could they map rebates to NDCs and dollar amounts? Options: Yes, with full line-item detail, Yes, but only at category level, No, they can't explain it, Unsure
• On a scale from 'completely confident' to 'deeply skeptical', how do your finance and benefits teams view your PBM reporting? Options: Completely confident, Generally confident, Some doubts, Deeply skeptical
• Where have you seen the biggest mismatches between PBM reporting and your internal expectations (select all that apply)? Options: Rebate pass-through amounts, Spread on generics, MAC guarantee adherence, Specialty drug site-of-care claims, 340B impacts, Formulary rebate aggregation
• Tell a concrete story about a time your team questioned a PBM line item or rebate—what happened and what did it cost (if known)?
• How often do finance and clinical leaders meet to reconcile pharmacy spend concerns today? Options: Weekly, Monthly, Quarterly, Ad hoc/as-needed, Never

Where the Dollars Might Be Slipping: What Are You Suspecting?

• Which area of your pharmacy spend do you suspect is most likely hiding excess cost right now? Options: Specialty drugs, Generics (spread pricing), Rebate aggregation/retention, MAC pricing gaps, 340B carve-in/out issues, Site-of-care / outpatient infusion
• Approximately how much of your annual pharmacy spend is specialty vs. non-specialty today (percentage)? Options: Under 20%, 20–40%, 40–60%, 60–80%, 80%+
• Have you seen recent spikes tied to specific drug launches or biosimilar dynamics? If so, which drugs or classes?
• Do you suspect inappropriate site-of-care billing or avoidable infusion facility utilization in your population? Options: Yes—significant, Yes—some, No, Unsure
• If you had to assign a financial risk band to these suspicions, what would it be? Options: >$1M/year, $250k–$1M/year, $50k–$250k/year, <$50k/year, Unknown

What Would NDC-Level Certainty Change for You?

• If we delivered NDC-level audit evidence showing dollar-level discrepancies, how would that alter your renewal posture? Options: Initiate immediate renegotiation, Use findings to demand credits/rebates, Require contract remediation clauses, No change—we'd keep current course, Unsure
• Which internal stakeholders must see NDC-detail to greenlight action (select all that apply)? Options: CFO/Finance, Director of Benefits, Procurement, External Legal, Healthcare Clinicians/Pharmacy Director, Board/Executive Committee
• What minimum dollar or percentage savings would constitute an actionable finding for you? Options: >$1M, $500k–$1M, $250k–$500k, <$250k but strategic, Any verified overpayment
• How definitive does the evidence need to be for you to pursue contract dispute or remediation (e.g., audit report + vendor response, legal opinion, independent expert)? Options: Detailed audit report + vendor response, Third-party legal opinion, Independent expert validation, Internal finance sign-off only, Other
• What would a successful NDC audit look like in three months—describe the specific outputs you'd expect?

Trust & Independence: Let’s Be Crystal Clear

• How important is an advisor’s documented independence from PBMs/manufacturers when you evaluate recommendations? Options: Absolutely essential, Very important, Somewhat important, Not important
• Have you required signed conflict-of-interest disclosures from advisors in previous renewals? Options: Yes, always, Sometimes, Rarely, Never
• Would your team require us to sign a formal independence disclosure before starting an audit? Options: Yes, Maybe—depends on wording, No
• Have you worked with PBM-affiliated advisors before, and if so, how did that relationship influence outcomes?
• How would discovering an advisor conflict midway through a review affect your willingness to act on findings? Options: We'd pause and reassess, We'd seek second opinion, We'd ignore that advisor's input, Depends on evidence quality

Data Reality Check: Can We Get What We Need?

• If the PBM resisted producing NDC-level claims extracts, what would you be willing to do to obtain them? Options: Escalate contractually, Use legal discovery, Request data from TPAs/ASOs, Abandon audit, Unsure
• Which of the following data sources can you access today or obtain within 30 days? Options: PBM NDC-level claims export, Encounter files (medical pharmacy), Rebate schedules & reconciliation, MAC pricing logs, Formulary & clinical rules, None of the above
• How long (realistic estimate) would procurement or your PBM take to deliver complete NDC-level claims data? Options: <2 weeks, 2–6 weeks, 6–12 weeks, 12+ weeks, Unwilling/unknown
• Do you have data-sharing agreements or legal permission to share de-identified claims with an independent auditor? Options: Yes—already in place, Can be obtained quickly, Requires legal review, No/likely blocked
• Who internally will own pulling or approving datasets (name/role), and how do we coordinate with them?

What Keeps Procurement and Benefits Leaders Up at Night?

• What would be the reputational or financial fallout if a three-year renewal embedded hidden spread or retained rebates? Options: Major—board-level issue, Significant—material financial impact, Moderate—manageable, Minimal
• Have past renewals included clauses that made auditing or verifying pricing difficult? If yes, which clauses (e.g., aggregate rebate pools, opaque aggregator language)?
• How involved is procurement in setting PBM contract acceptance criteria today? Options: Leading, Collaborating, Advisory only, Not involved
• What operational constraints would limit your ability to change PBMs or contract terms at renewal (e.g., vendor relationships, employee benefit impacts, union agreements)?
• If a discovery shows significant overpayment, how much time would your team realistically need to act before renewal? Options: Immediate—within weeks, 1–3 months, 3–6 months, 6+ months

What Would a Successful Pilot Prove?

• If we ran a historical claims pilot, what single proof would convince you to move forward with a retainer for renewal work? Options: Documented dollar recoveries, Clear contract violations, Rebate shortfall reconciliation, Operational feasibility of our recommendations, Other
• Which KPIs must the pilot include to be considered successful (select up to 4)? Options: Total verified savings ($), Estimated annualized savings (%), Number of contract violations identified, Rebate pass-through percentage, NDC-level discrepancy count, Time-to-evidence (days)
• What minimum dollar threshold would make a pilot ‘material’ for your finance team to act on? Options: $1M+, $500k–$1M, $250k–$500k, <$250k but strategic
• What deliverables and formats do your stakeholders expect from a pilot (e.g., slide deck, audit workbook with NDC line-items, executive summary)? Options: Executive summary, Audit workbook (NDC-level), Slide deck for execs, Detailed reconciliations for finance, Legal-ready findings
• Who must sign off on pilot results before you’d commit to a retainer (list roles and any required governance committee)?

Change Leadership: Who Will Carry This Forward?

• When we deliver findings that require hard conversations with your incumbent PBM, who will lead that negotiation internally? Options: CFO, Director of Benefits, Procurement, In-house Counsel, External Consultant, Other
• Who are the stakeholders that will resist change most, and what are their primary concerns (budget, relationships, operational burden)?
• What internal approvals are required to allocate a retainer for renewal work (roles and estimated approval time)?
• Have you previously executed a remediation or renegotiation with a PBM—what worked and what surprised you?
• Which support would make you most comfortable moving ahead after discovery (select top 2)? Options: Legal playbook for disputes, Finance-ready reconciliations, Executive summary for board, Vendor engagement scripts, Training for internal stakeholders

Next Steps & Comfort Signals: What Do You Need to Proceed?

• If we proposed a 60–90 day discovery that includes an NDC pilot, what’s the smallest concrete sign-off you’d require to say ‘go’? Options: NDA + data access approval, Signed SOW for pilot, Executive email approval, Preliminary budget allocation
• What timing works for your team to start discovery (select earliest realistic start)? Options: Immediately (this month), Within 1 month, 1–3 months, 3+ months, Dependent on approvals
• What are the top three blockers that would prevent you from starting discovery right away?
• How do you prefer we report interim findings while discovery is in progress? Options: Weekly brief email, Bi-weekly stakeholder call, Shared dashboard access, Milestone-based reports only
• Any final concerns or questions you want us to address before a pilot scope is proposed?