Why this renewal feels different

• To begin, what specifically pushed you to request an independent PBM audit for this renewal?
• Walk me through the timeline of your current PBM contract, including the expiration date and any auto-renew clauses.
• During the last 12 months, which unexpected pricing or rebate items did finance flag in PBM reports? Options: Specialty drug inflation, Generic pricing anomalies, Rebate timing or shortfalls, Site-of-care spend shifts, Other
• Estimate the portion of annual pharmacy spend you suspect could be recoverable if hidden spread or retained rebates are corrected. Options: Less than 0.5%, 0.5%–1.5%, 1.5%–3%, More than 3%
• Who in your organization will be most affected if the audit finds multi-million dollar discrepancies? Options: CFO/Finance, Director of Benefits/Total Rewards, Procurement, Legal/Compliance, External benefits consultant
• Can you proceed with an audit that completes after the renewal decision, or must findings arrive before signature to be specific? Options: Must complete before renewal decision, Findings after renewal still useful, Unsure, need to confirm internal timeline

Where the dollars might be slipping through the cracks

• Estimate the dollar range you consider material for this audit, and describe the financial consequence if that range is confirmed. Options: <$250k, $250k–$1M, $1M–$5M, >$5M
• Describe a recent example where PBM reporting left your team unable to reconcile a rebate or generic pricing line item.
• How often do you receive NDC-level detail from the PBM versus aggregated category summaries? Options: NDC-level monthly, NDC-level quarterly, Only aggregated reports, Ad hoc on request
• If the audit identifies specific NDCs with overpayment, what minimum dollar impact would compel you to pursue contract change or negotiation? Options: Any verified overpayment, $100k+, $500k+, $1M+
• Which savings levers would you prioritize if the audit shows issues, select all that apply. Options: Rebate pass-through correction, MAC guarantee enforcement, Therapeutic substitution programs, Biosimilar conversion, Site-of-care optimization, 340B carve-in optimization

Who needs to be convinced, and how decisions actually happen

• Who on your leadership team has final approval authority for multi-year PBM contracts and why?
• Tell me how procurement, benefits, and finance currently coordinate during a renewal review, including typical meetings or decision gates.
• Share an example of a past renewal decision where incentives or relationships influenced the outcome and what you learned from it.
• How many formal approvals or committee signoffs are required before a PBM contract is executed? Options: 1, 2, 3–4, More than 4
• If the audit validates your concern about overpayment, who must authorize the change in direction and how quickly can they act?

Where the platform will need to reach, and what that access looks like

• Assume the PBM resists providing NDC-level claims, what fallback sources or tactics could you use to produce the same analysis? Options: Claims from TPAs or carriers, Pharmacy network reports, Specialty vendor extracts, Legal subpoena or negotiation, No fallback available
• Identify every system that currently stores pharmacy claims, rebate records, or contract files you can grant access to. Options: Benefits admin system, TPA claims warehouse, Finance ledger, Custom SFTP locations, Other
• Which internal owner controls requests to the PBM and has authority to approve NDC-level extracts? Options: Director of Benefits, VP of Finance, Procurement lead, General counsel, IT/data owner
• Describe the formats and cadences of extracts you can provide today, for example daily API, weekly SFTP CSV, or monthly files. Options: Daily API, Daily SFTP/CSV, Weekly extracts, Monthly extracts, Ad hoc exports
• What single data gap, if unresolved, would prevent completion of an NDC-level audit in time to influence your renewal?

Operational readiness, gating items, and who will do the work

• Identify any legal, security, or governance blockers that could stop data transfer or delay fieldwork beyond your target timeline. Options: Data use agreement required, Security review pending, Vendor non-disclosure limits, Executive sign-off needed, No known blockers
• Confirm whether your legal team requires a separate data use agreement, a security questionnaire, or external counsel review before claims can be shared. Options: DPA/data use agreement, Security questionnaire, External counsel review, None required
• How many full time equivalents or named individuals can your team dedicate to the audit and platform onboarding over the next 90 days? Options: None, 1–2 people, 3–5 people, More than 5 people
• List the compliance frameworks or certifications your security team requires for vendor access, for example encryption standards or SOC reporting. Options: SOC 2 type II, ISO 27001, Encryption at rest and in transit, Scoped data handling procedures, Other
• Would inability to commit required headcount or to sign data access within 30 days force you to lock current PBM terms? Options: Yes, must lock current terms, No, we can extend timeline, Unsure, need internal confirmation

Risks that can halt the audit or limit its impact

• Name the most likely source of pushback that would lead stakeholders to dismiss audit findings. Options: PBM contract interpretation, Alleged data quality issues, Advice from incumbent consultant, Political/internal reluctance, Other
• Explain the responses you expect from the PBM when a vendor flags NDC-level pricing or rebate discrepancies. Options: Immediate remediation offer, Data dispute and challenge, Contractual defense, Delayed cooperation, Refusal to share more detail
• How quickly does your legal or procurement team escalate vendor disputes and what typical resolution path do they follow? Options: Immediate executive escalation, Formal dispute process, Mediation or negotiation, Accept and monitor, Other
• In that case, which governance step would your team take if a PBM refuses to honor audit requests or legal holds, and could that step stop the engagement? Options: Escalate to CFO, Engage outside counsel, Pause evaluation, Seek alternative data sources, Proceed despite refusal

Competitive options you are weighing

• List every alternative you have evaluated or are actively considering, including the incumbent PBM and any internal audit plans.
• Have any internal teams proposed handling this audit without an outside vendor or partner? Options: Yes, internal benefits team, Yes, internal analytics team, No internal proposal, Not sure
• Tell me who originally recommended your current PBM, and whether that party has any ongoing financial relationship that could create perceived bias. Options: External consultant/advisor, Broker or consultant with PBM ties, Internal procurement recommendation, Unknown
• For you to keep the incumbent PBM rather than change vendors after the audit, what would have to be true? Options: No material findings, PBM offers immediate remediation, Savings below our threshold, Contractual barriers to change, Other

If the numbers check out, how fast can you move

• Could leadership approve contract changes within 30 days if the audit confirms material overpayment? Options: Yes, 30 days or less, Maybe with expedited approvals, No, longer timeline required
• Name the stakeholders who must review and sign commercial changes for a midterm correction versus a full RFP. Options: CFO/Finance, Director of Benefits, Procurement, General counsel, CEO/Board
• By when do you need final audit data to influence the next negotiation cycle, for example 60 days before renewal? Options: More than 90 days before renewal, 60–90 days before renewal, 30–60 days before renewal, Within 30 days of renewal
• What single decision or signature would accelerate a purchase to close within your desired timeline?
• Select how soon you want an initial findings report after the platform receives data. Options: 10 business days, 20 business days, 30 business days, Rolling preliminary findings

How we should work together if we move forward

• Before we proceed, what single communication channel and cadence will keep stakeholders informed without creating extra review work? Options: Weekly executive summary email, Biweekly cross-functional call, Dedicated collaboration channel with alerts, Ad hoc briefings only
• Please name the primary point of contact on your side for data, decisions, and issue escalation, and their role.
• How do you prefer draft findings to be delivered, for example an executive summary first, a full NDC-level appendix, or both? Options: Executive summary first, Full NDC-level appendix first, Both concurrently, A phased rollout
• Would you allow the seller to present preliminary findings to a small cross-functional committee for immediate triage? Options: Yes, Maybe, with conditions, No
• Are there internal approvals already in place to act within six weeks if the audit shows your net cost is materially higher than reported? Options: Yes, approvals in place, Approvals possible with expedited review, No approvals in place

• Solution Experience: Audit & Platform Plan

• Confirm the current state and its cost to your team
• You confirm the stated current state and the estimated urgency and dollar-level consequence that make this work mission-critical.
• Provide 12 months of de-identified paid claims, rebate statements, and the current PBM contract excerpts that reference rebates, spread, and MAC guarantees.
• You confirm the demonstrated workflow produces NDC-level findings you trust and that the platform's reconciliation maps to contract language you care about.
• Prove the NDC-level discrepancy detection with a representative claim scenario
• Provide a list of decision-makers, the renewal timeline, and any contract deadlines that would affect fieldwork scheduling.
• You agree to the proposed audit scope, success criteria, and the next-step deliverables and timeline required to keep the work inside the renewal window.
• Show how the platform reconciles rebates and supports ongoing monitoring
• Run a sample NDC-level audit on the provided 90-day claims and deliver a preliminary dollar-level findings summary before the follow-up session.
• Validate that this maps to your need
• Prepare a draft audit scope with measurable NDC-level success criteria and a proposed monitoring cadence for review in the follow-up session.
• Agree next steps, timeline, and responsibilities

• Solution Experience: Audit & Platform Plan
• Solution Experience Deck
• Solution Brief

• meeting
• slides
• document

• Ingest and Normalize Claims Data
• Configure Contract Terms and Guarantees Mapping
• NDC-Level Pricing Reconciliation
• Rebate Pass-Through Reconciliation by Invoice/NDC
• MAC and Spread Compliance Monitoring
• Pricing Benchmark Calibration and Indexing
• NDC-Level Savings Modeling and Projection
• Therapeutic Substitution Implementation
• Biosimilar Conversion Program Execution
• Specialty Drug Site-of-Care Redirection Program
• 340B Identification and Carve-In Optimization
• Recover Overpayments and Claims Remediation Support
• Live Claims Monitoring and Alerting Dashboard
• Platform Training and Operational Handoff

Ingest and Normalize Claims Data

• Which claim file types can you provide for the baseline period (select all that apply)? Options: Adjudicated pharmacy claim detail (flat file), NCPDP format extract, PBM proprietary CSV/pipe-delimited, 835 remittance / ERA, Rebate remittance files, Other
• How many months of adjudicated claim lines do you want included in the baseline audit? Options: 3 months, 6 months, 12 months, 24 months, Other
• Do the claim extracts include the following fields: NDC, paid ingredient cost, dispensing fee, days supply, quantity, BIN/PCN, group ID, patient-member ID? Options: All included, Some included - will list missing fields, No, only summary fields
• Who in your organization owns the claims extracts and will approve access (title or role)?
• When do you have a sample claims file available for schema mapping and test ingest? Options: Within 1 week, 1-3 weeks, 3-6 weeks, No sample available

Configure Contract Terms and Guarantees Mapping

• Provide the contract documents or PDF pages that contain guarantees, pass-through percentages, MAC list clauses, and rebate schedules for the contract to be audited.
• List the contract effective dates and renewal window you want the audit to cover (start date and end date).
• Specify the guarantee types to map at NDC level (select up to three): Options: MAC price floor/ceiling, Ingredient cost guarantees, Spread pricing caps, Rebate pass-through percentage, Dispensing fee guarantees
• Identify any contract clauses that limit data use, require anonymization, or define independent-audit procedures (attach clause identifiers or page numbers).
• Are contract interpretation disputes expected and who will be the internal contract reviewer for clarification on ambiguous clauses (title or role)? Options: Yes - legal counsel available, Yes - benefits lead available, No disputes expected
• Are the following activities out of scope for this engagement (select all that apply)? Options: Negotiating contract changes with the PBM, Providing legal representation, Implementing formulary changes in the PBM portal, Pursuing litigation to recover funds

NDC-Level Pricing Reconciliation

• Specify which pricing benchmarks you want reconciled against adjudicated paid amounts for each NDC (choose up to two): Options: NADAC (National Average Drug Acquisition Cost), WAC (Wholesale Acquisition Cost), AWP (Average Wholesale Price), Contract MAC list, Custom benchmark (specify)
• How will you identify invoice-to-claim linkage for reconciliation (select the primary mapping key)? Options: NDC + claim date + paid amount, Invoice line ID provided by PBM, Manufacturer rebate code + NDC, Other mapping key
• Do any of your claims use National Drug Code (NDC) variants or billing NDCs that require mapping to a standard NDC table (RxNorm or internal crosswalk)? Options: Yes - we'll provide a crosswalk, Yes - need assistance building crosswalk, No - NDCs are standardized
• Indicate the dollar or percentage tolerance for reporting a pricing exception at NDC level (examples: $0.25 per claim, 5% above benchmark). Options: $0.10 per claim, $0.25 per claim, 5% above benchmark, 10% above benchmark, Custom (specify)
• What acceptance criteria will confirm the reconciliation baseline is complete (for example, >=98% of adjudicated claim lines ingested and mapped to an NDC)?

Rebate Pass-Through Reconciliation by Invoice/NDC

• Which rebate artifacts can you provide for the contract period (select all that apply)? Options: Aggregate rebate invoices by manufacturer, Line-item rebate invoices referencing NDCs, Quarterly remittance statements, Manufacturer rebate schedules
• How are rebate payments currently remitted and documented (select one)? Options: Monthly PBM invoice credit, Quarterly check or ACH, Offset in premium reconciliation, Other format
• Specify how manufacturer-level rebate schedules should be mapped to NDCs for pass-through (attach schedule naming convention or example).
• Who in your finance or pharmacy team can confirm reconciliation of rebate remittances to PBM invoices if discrepancies are identified (title or role)?
• Are rebate aggregation or allocation rules in contract wording that restrict NDC-level pass-through attribution (for example, pooled rebates by therapeutic class)? Options: Yes - pooled allocation, Yes - tied to formulary tiers, No - pass-through at NDC

MAC and Spread Compliance Monitoring

• Which MAC (Maximum Allowable Cost) source should be authoritative for monitoring: contract MAC list, PBM portal MAC, or published third-party MAC? Options: Contract MAC list, PBM portal MAC, Third-party published MAC (specify), Hybrid - use contract then portal
• How frequently do you receive MAC list updates and do you want those updates ingested automatically for ongoing monitoring? Options: Weekly, Monthly, Quarterly, Ad-hoc/manual
• Describe any spread pricing disclosure thresholds in the contract that must trigger an alert (for example, spread >$10 per claim or >15% of benchmark).
• Who will be responsible for responding to a MAC appeal timeframe when we flag a MAC violation (title or role)?
• Are there specific pharmacies or pharmacy networks excluded or carved out from MAC/spread guarantees in your contract? Options: Yes - specified in contract, Yes - will provide list, No exclusions

Pricing Benchmark Calibration and Indexing

• Select how you want benchmarks indexed over time for trend comparison: Options: Fixed benchmark snapshot, Rolling 12-month benchmark, Inflation-adjusted index, Custom indexing
• Which external benchmark sources do you accept for specialty pricing indexing (select all that apply)? Options: NADAC, WAC, Medi-Span, Custom purchased benchmarks
• Do you want automated alerts when benchmark divergence exceeds a threshold for a high-dollar NDC (specify threshold)? Options: Yes - require alerts, No - manual review only
• Identify any internal pricing overrides or manual adjustments we should apply when calibrating the benchmark (for example, negotiated distributor discounts).
• Are there bench-marking acceptance constraints we must meet for reporting (for example, minimum benchmark coverage of 95% of NDC spend)? Options: Yes - specify threshold, No minimum required

NDC-Level Savings Modeling and Projection

• Choose the time horizon for savings projections: Options: 12 months, 24 months, 36 months, Custom
• Estimate the baseline spend period to use for modeling (select one): Options: Most recent 12 months, Calendar year, Rolling 12 months excluding outliers, Custom period
• Describe which intervention scenarios you want modeled at NDC level (select up to three): Options: Therapeutic substitution, Biosimilar conversion, Site-of-care redirection, 340B carve-in optimization, Prior authorization tightening
• Indicate clinical or operational constraints that must be applied to projected savings (examples: no substitution for narrow therapeutic index drugs, provider consent required).
• Are there reporting slices required for finance review (for example, savings by cost center, by plan tier, or by therapeutic class)? Options: By cost center, By plan tier, By therapeutic class, Custom

Therapeutic Substitution Implementation

• Which therapeutic classes do you want targeted first for substitution (provide specific class names or examples)?
• Do you require clinical review and approval workflows mapped into the substitution program (for example pharmacist review, medical director signoff)? Options: Yes - pharmacology review required, Yes - medical director only, No - operational team only
• Specify whether substitution should be implemented via formulary PD/PA edits, prior authorization, or prescriber outreach. Options: Formulary edits, Prior authorization, Prescriber outreach, Combination
• Who will approve communication templates to prescribers or members for therapeutic substitution (title or role)?
• Are there clinical exclusion lists we must respect (for example, disease states or patient subgroups where substitution is prohibited)? Options: Yes - we will provide list, No exclusions

Biosimilar Conversion Program Execution

• List the biologic molecules in your claims population you want evaluated for biosimilar conversion (attach NDCs or therapeutic names).
• Which legal or state substitution constraints must the program respect (for example, interchangeability rules, prescriber notification laws)?
• Describe provider acceptance risk and whether you want direct provider outreach or incentive alignment included. Options: Direct outreach, Incentive programs, Provider education only, No outreach
• Specify whether step therapy or preferred product edits should be simulated before implementation. Options: Simulate step therapy, Simulate preferred product edits, Do not simulate
• Are there patient continuity requirements we must enforce (for example, patients on an originator cannot be auto-switched)? Options: Yes - grandfather current patients, No - open conversion allowed

Specialty Drug Site-of-Care Redirection Program

• Which site-of-care shifts are you targeting (select all that apply)? Options: Infusion center to home infusion, Hospital outpatient to physician office, Hospital outpatient to ambulatory infusion center, Other
• Which place-of-service codes or billing indicators should we use to identify site-of-care claims in the data?
• What minimum per-claim cost delta must be present to consider redirection (for example, $500 or 25% differential)? Options: $100, $500, 25% differential, Custom threshold
• Who will approve patient continuity and clinical safety checks before site-of-care changes are recommended (title or role)?
• Are there vendor relationships (home infusion providers, specialty pharmacies) you require we exclude or include in redirection recommendations? Options: Exclude specified vendors, Include preferred vendors, No vendor restrictions

340B Identification and Carve-In Optimization

• Do you have a canonical list of 340B covered entities to match against prescribing NPI or dispensing pharmacy identifiers? Options: Yes - will provide list, No - need assistance building list
• Which identifiers should be used to detect 340B claims (select all that apply)? Options: Prescribing NPI, Dispensing NPI, Place-of-service, 340B indicator on invoice
• Describe desired carve-in outcomes (examples: re-price claims, exclude from network, pursue refund) and which outcome is preferred.
• Are there contract clauses specifically addressing 340B that we must map and monitor (attach clause pages if available)? Options: Yes - attach clauses, No specific clauses
• Who in your organization will sign off on 340B remediation recommendations (title or role)?

Recover Overpayments and Claims Remediation Support

• Which recoverable event types do you want pursued (select all that apply)? Options: Overpaid ingredient costs, Incorrect dispensing fees, Rebate shortfalls, Duplicate paid claims
• Specify any statutory or contractual lookback window we must respect when submitting recovery requests (for example, 12 months). Options: 6 months, 12 months, 24 months, Other
• How should recovered funds be handled if returned (select one)? Options: Directly to plan sponsor bank account, Applied as credit on future invoices, Split according to plan instructions
• Describe whether you want us to perform claim-level remediation or provide a prioritized findings package for your team to act on. Options: Perform remediation (fixed-fee), Provide prioritized findings only, Hybrid approach

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Subscription Agreement
• Order Form & Fee Schedule
• Data Access Authorization
• Data Processing Agreement (DPA) / HIPAA Business Associate Addendum (BAA)
• Independence & Conflict of Interest Disclosure
• Service Level Agreement (SLA)
• Change Order Agreement
• Termination & Data Transition Agreement

• desired_state
• success_criteria
• decision_readiness
• gaps
• stakeholders
• current_state
• decision_readiness
• gaps
• success_criteria
• desired_state
• current_state
• stakeholders
• stakeholders
• desired_state
• decision_readiness
• current_state
• success_criteria
• gaps
• decision_readiness
• decision_readiness
• decision_readiness
• decision_readiness

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate, Outcomes Certification (around day 90)
• Ongoing Reviews, Monthly Operational Check-in
• Quarterly Business Review

• Close the top 5 exceptions in the queue and publish updated reconciliation results.
• Execute the incumbent data archival or read-only configuration and publish confirmation of archival completion.
• Open remediation tickets for any failed criteria with specific resolution dates and tracking in the shared channel.
• Review monthly realized savings and reconciliation outcomes
• Validate the monthly realized savings run-rate in dollars is tracking to the quarterly target recorded in Engagement Scope or capture corrective actions if not.
• Reduce the NDC-level discrepancy backlog count month over month and close the highest-dollar exceptions.
• Prioritize and schedule resolution or roadmap placement for outstanding enhancement requests.
• Reconfirm scope and acceptance criteria
• Publish a prioritized enhancement list with estimated delivery quarters for requests raised in the shared channel.
• Confirm next monthly check-in date and any special data extracts required for that meeting.
• Cumulative outcomes versus Engagement Scope targets
• Confirm cumulative realized savings YTD in dollars and rebate pass-through recovery percentage relative to Engagement Scope targets.
• Agree the schedule and scope for the next independent audit and the quarterly executive reporting package.
• Document any contract risk items that require remediation and assign tracking in the shared channel.
• Schedule the next independent audit and publish the audit scope and timeline to the shared workspace.
• Publish the quarterly executive summary including reconciliations, savings realized, and outstanding contract risks.
• Update the enhancement roadmap with committed delivery quarters for items approved in the review.
• Confirm the deployment completed per the deployment checklist and that initial reconciliations have run successfully.
• Document the top 3 operational blockers with agreed remediation actions and target dates.
• Verify that training completion and basic user access are in place for the buyer's finance and clinical reviewers.
• Deliver an errors and exceptions report for the initial ingestion run and a remediation plan for each issue.
• Publish a short how-to note on accessing the reconciliation dashboard and reading NDC-level findings.
• Schedule the First Measurement Review within 4-10 weeks post go-live.
• Present first measurement data
• Validate whether realized savings to date in dollars are on track versus targets recorded in Engagement Scope.
• Confirm the NDC-level discrepancy count and rebate pass-through shortfall dollars are understood and have root-cause owners.
• Agree a corrective action plan with dates that moves the engagement to the Acceptance Gate window.
• Produce a root-cause analysis for the top 5 NDC discrepancies and circulate to the shared channel.
• Adjust pricing benchmark parameters or contract-rule thresholds identified as causes of false positives, and document the change log.
• Prepare the dataset and executive summary required for the Acceptance Gate meeting.
• Restate acceptance criteria from Engagement Scope
• Produce a documented acceptance decision against each numeric target recorded in Engagement Scope.
• Confirm incumbent system is either decommissioned or formally retained read-only and that data archival/migration is complete.
• Agree remediation plan and deadlines for any unmet criteria, with the tracking channel identified.
• Publish the acceptance decision and the outcome summary to the shared workspace for the buyer's finance and clinical reviewers.
• Deployment and ingestion validation
• Contract compliance and risk review
• Present outcome data versus each criterion
• Root-cause diagnosis for metric gaps
• Monitor claim-validation rate and exception queue
• Recurring audit and monitoring cadence confirmation
• Corrective action planning
• Early adoption signals and usage patterns
• Document pass, fail, or conditional per criterion and capture formal acceptance
• Issue and enhancement triage
• Short operational housekeeping
• Confirm timeline to Acceptance Gate
• Incumbent wind-down and data handover
• Open issues, blockers, and remediation plan
• Enhancement roadmap and prioritization
• Agree remediation items and escalation path for any failed criteria