Who sits at the table for specialty care

• Tell me who typically owns specialty pharmacy decisions and contract signoff at your organization Options: Pharmacy director / VP specialty, Medical director, Network management, PBM contracting, Procurement / CFO, Other - please name
• How many members in your covered population are actively on specialty medications today Options: < 1,000, 1,000 to 5,000, 5,001 to 20,000, 20,001 to 100,000, > 100,000
• Which therapeutic areas make up the majority of your specialty spend Options: Oncology, Autoimmune / Rheumatology, Neurology / MS, HIV / Hepatitis, Rare disease / Gene therapy, Other
• Which of these models best describes how you currently source specialty dispensing Options: Single contracted specialty partner, Multiple contracted specialty partners, In-house dispensing, Retail carve-out plus specialty partners, Hybrid or other
• In the last 12 months, how often have you changed or escalated concerns about a specialty pharmacy relationship Options: Never, Once, 2 to 3 times, 4+ times, Currently under review

Where patients trip up in the first 30 days

• If a single breakdown in the early patient experience could make you cancel a partner, which failure would cause that decision Options: Prior authorization delay, Failure to enroll in financial assistance, Cold-chain / shipping failure, Poor care coordination with prescribers, Unacceptable patient dropout
• Walk me through a typical member's path from prescription to first fill for a complex therapy at your organization
• Across those first 30 days, how often do first fills meet your internal target for therapy start Options: Almost always (within target window), Often (minor delays), Sometimes (noticeable delays), Rarely (frequent missed starts)
• Which step causes the most patient dropout: benefit investigation, prior authorization, financial assistance enrollment, hospital discharge coordination, or shipping Options: Benefit investigation, Prior authorization, Financial assistance enrollment, Hospital discharge coordination, Shipping / cold-chain
• If starts do not meet your target window for three consecutive months, would you pull a pilot, require remediation, or take another action Options: Pull the pilot and stop, Require remediation and continue, Renegotiate scope and continue, Escalate to executive review

When prior authorizations stop progress

• How often does incomplete clinical documentation from prescribers cause a start delay that exceeds your acceptable window Options: Almost never, Occasionally (monthly), Regularly (weekly), Frequently (multiple times weekly)
• Which communication channels do your top prescribers use for documentation and prior authorization support Options: EHR direct messaging / integration, Fax, Secure provider portal, Phone calls, Email
• Who inside your organization is responsible for chasing missing clinical documentation for prior authorizations Options: Pharmacy operations team, Clinical care management / nurses, Provider relations, Third-party vendors, Other
• Walk me through the typical timeline and owners when a prior authorization is denied and moves to appeal
• If prior authorization turnaround cannot be improved to your target, would that stop you from selecting a partner Options: Yes, it would block selection, No, other factors could compensate, Depends on severity and exceptions, Unsure
• What is your target average prior authorization turnaround for specialty medications Options: < 24 hours, 24 to 48 hours, 48 to 72 hours, > 72 hours

Cold-chain, shipping, and high-risk logistics

• When a biologic or cold-chain shipment arrives outside temperature range, what immediate action or cost does your team require to consider the event closed Options: Immediate product replacement at vendor expense, Investigation and corrective action plan, Financial reimbursement only, Clinical review and patient outreach
• Describe your current process for validating cold-chain handling, temperature logging, and returns for specialty products
• Which fulfillment constraints concern you most for specialty therapies Options: Limited distribution drugs, Hospital discharge timing, Remote patient locations, Patient refusal / first-fill abandonment, Controlled substance logistics
• How often do shipping or fulfillment problems lead to therapy interruption for members Options: Never, Rarely, Occasionally, Monthly, Weekly
• Who is the accountable owner for temperature excursions, lost product, and recovery costs inside your organization Options: Pharmacy operations, Clinical quality / risk, Supply chain / logistics, Procurement, Other

Data gaps that block outcomes and value contracts

• If you could add one specific data feed that would allow you to prove adherence-linked savings, which feed is missing today Options: Dispensing events with timestamps, Real-time claims adjudication, Patient-reported outcomes, Provider clinical notes, Temperature logs for shipped biologics
• Which of these data sources do you currently receive from external partners Options: Claims adjudication / paid claims, EHR clinical summaries, Dispense events / NCPDP, Patient experience / satisfaction surveys, None of the above
• How would you describe the timeliness and cleanliness of the claims and clinical feeds you rely on today Options: Near real time and reliable, Daily batch, mostly reliable, Weekly or irregular batches, Incomplete or requires heavy cleansing
• Which reporting cadence and delivery method best supports your decision makers for specialty performance Options: Weekly dashboard access (API), Monthly PDF executive report, Quarterly clinical detailed review, Daily operational alerts, Ad hoc on request
• If a partner cannot meet your required data granularity and reporting timeline, would that block contracting Options: Yes, it would block, No, we can accept compromises, Depends on compensating benefits, Unsure

Who will do the heavy lifting internally

• Which internal resource shortage would stop this project before it begins: integrations, legal review, or clinical staffing Options: Integrations / IT capacity, Legal / privacy approvals, Clinical staffing for case management, No single shortage would stop it
• Are there named owners available for integrations and for clinical workflow coordination Options: Yes, both assigned, IT owner only, Clinical owner only, No owners assigned yet
• How many full time equivalents can you commit to a deployment pilot across IT, clinical, and operations Options: 0, 1 to 3, 4 to 6, 7 to 15, 16+
• Which integration methods are available for your claims, roster, and EHR systems Options: Public APIs with vendor support, APIs managed internally, SFTP / batch files, HL7 / clinical interfaces, No integration options currently
• Which compliance or legal reviews tend to add the most schedule risk to projects like this Options: Privacy / BAA review, Data-sharing agreement negotiation, Formulary and medical policy approval, State regulatory filings, Other
• Is there a hard go or no-go committee or checkpoint that must approve before a pilot can begin Options: Yes, named committee with formal vote, Yes, approval required but ad hoc, No formal checkpoint, Unsure

The other options you're weighing

• Which vendors, incumbents, or internal solutions are you actively considering instead of engaging an external specialty partner
• For each alternative you named, what single advantage do they claim that matters most to your team Options: Lower price, Existing contractual relationship, Better integration with current systems, In-house control, Clinical specialization
• What would have to be true about your current approach for you to stay with it rather than change partners
• Has anyone proposed building specialty dispensing and management internally, and if so which team would lead Options: Yes, IT, Yes, Pharmacy operations, Yes, Clinical care management, No internal proposal
• If the incumbent agreed to match key SLA items during a pilot, would you still consider switching to a different partner Options: Yes, we would still switch, No, matching SLAs would keep us, Maybe, depending on total cost and outcomes, Unsure

What would make you sign

• If a pilot proves the KPIs, what single approval or signature would unlock contracting and deployment the following week Options: Pharmacy director signature, Medical director signoff, Procurement / CFO approval, Executive committee approval
• Which KPIs would you require to consider a pilot successful: adherence, prior authorization turnaround, first-fill abandonment, patient satisfaction, or cost avoidance Options: Adherence (PDC/MPR), Prior authorization turnaround, First-fill abandonment, Patient satisfaction / NPS, Cost avoidance / spend reduction
• What's your target relative improvement for the KPIs you selected to justify a full rollout Options: 5 to 10%, 10 to 20%, 20 to 40%, 40%+
• What is the expected timeline from a successful pilot to enterprise deployment if targets are met Options: Less than 3 months, 3 to 6 months, 6 to 12 months, More than 12 months
• Is there pilot funding already allocated and if so how much is committed to a pilot Options: Yes, pilot funding allocated, Budget exists but not for pilot, No budget allocated, Unsure

• Clinical Program Walkthrough

• Confirm the current state and its cost to your team
• Customer confirms the demonstrated workflow eliminates the prescriber documentation rework and reduces prior-authorization delays.
• Run the three provided anonymized patient scenarios through the proposed prior-authorization and fulfillment workflow and deliver a timeline with exceptions and resolution steps.
• Customer agrees the fulfillment and cold-chain handling shown mitigates the clinical continuity risks they raised.
• Walk through Patient Scenario A end-to-end
• Provide sample clinical documentation templates and the exact fields required to satisfy payer prior-authorization criteria.
• Customer confirms the data and integration mapping meets their reporting and value-contract evidence needs.
• Provide a redacted fulfillment incident log showing past cold-chain exceptions and corrective actions for review.
• Walk through Patient Scenario B focusing on limited-distribution drug
• Customer and seller agree on the specific remaining evidence and timeline required to reach mutual commit.
• Show cold-chain and hospital discharge fulfillment for a biologic scenario
• Provide three representative patient cases including medication, known benefits/plan details, and prescriber contact for the scenario runs.
• Share current metrics for prior-authorization turnaround, first-fill abandonment, and cold-chain incident rates for the specialty population.
• Map integration and reporting handoffs for your systems
• Validate, is this what you meant by your requirements?
• Agree remaining evidence and decision criteria

• Clinical Program Walkthrough
• Clinical Program Walkthrough Deck
• Solution Brief — Clinical Program Walkthrough

• meeting
• slides
• document

• Verify benefits and coverage eligibility
• Submit and manage prior authorizations
• Prior authorization appeals and denial management
• Patient enrollment and first-fill support
• Dispense and ship specialty medications with cold chain
• Next-day fulfillment and trackable specialty shipping
• Coordinate hospital discharge medication handoffs
• Manage limited distribution drug access
• Manage copay and financial assistance enrollment
• Adherence monitoring and refill coordination
• Clinical counseling and side-effect management
• EHR ePrescribing and clinical documentation integration
• Deliver clinical outcomes and adherence reporting package

Verify benefits and coverage eligibility

• Which eligibility data source do you use for member benefit verification (270/271 batch file, real-time API, payer portal)? Options: 270/271 batch file, Real-time API (FHIR/R4), Payer web portal, EDI feed (periodic), Other
• How do you handle specialty carve-outs, step therapy, or prior authorization flags in your benefits file (automated rules, manual review)? Options: Automated rules in adjudication, Manual clinical review by payer, PBM adjudication only, Hybrid
• Describe the minimum eligibility fields required to confirm coverage for a specialty medication (plan ID, benefit tier, prior auth indicator, coverage start/end dates).
• Do you need benefits and eligibility verification for members across multiple lines of business (commercial, Medicare Advantage, Medicaid)? Options: Commercial, Medicare Advantage, Medicaid, All listed
• Who will own maintenance of eligibility mappings between your payer extracts and our verification logic? Options: Your IT team, Payer data operations, Third-party integrator, Shared responsibility to be defined

Submit and manage prior authorizations

• Which PA submission channels should we enable for your network (payer API, payer portal, NCPDP Real-Time Prior Authorization, fax fallback)? Options: Payer API, Payer portal, NCPDP Real-Time PA (if supported), Fax fallback
• How many distinct PA templates or criteria sets (by drug/indication) must be built from your clinical rules? Options: 1-10, 11-25, 26-50, 50+
• Describe the clinical documentation you require attached to PA submissions (labs, imaging, prior therapy history, provider progress notes).
• Do you require prior authorization turnaround SLAs for initial submissions (e.g., decision within 48 hours of complete submission)? Options: Yes - 24 hours, Yes - 48 hours, Custom SLA to define, No SLA required
• When a PA is conditionally approved pending additional documentation, how should we route follow-up to prescribers (EHR message, fax, phone, secure email)? Options: EHR message, Fax, Phone outreach, Secure email, Other

Prior authorization appeals and denial management

• Which denial reason codes from your payers must trigger an automatic appeals workflow (medical necessity, coding error, missing documentation)? Options: Medical necessity, Coding/claim error, Missing supporting docs, Benefit exclusion, Other
• How many levels of appeal does your plan require (internal review, external independent review)? Options: 1 (internal), 2 (internal + external), Other
• Identify the artifacts required to support an appeal for a specialty drug denial (provider progress notes, test results with dates, prior therapy logs).
• Do you want automated escalation timelines on denials (e.g., escalate to medical director after 5 business days)? Options: Yes - auto escalate, No - manual escalation only, Define custom timeline
• Have you defined success evidence for appeals handling (e.g., overturn rate target, average time-to-overturn)? Options: Yes - provide targets, No - we need to define targets

Patient enrollment and first-fill support

• Which enrollment triggers should initiate outreach (prescription transmitted to specialty pharmacy, hospital discharge, prior authorization approval)? Options: Rx transmission, PA approval, Hospital discharge, Provider referral, Other
• How many touchpoints do you expect in the first-fill process (benefits check, copay assistance verification, counseling, shipment confirmation)? Options: 1-2, 3-4, 5+
• Describe the documentation you require at first fill (signed informed consent, medication guide acknowledgement, temperature-sensitive shipment consent).
• Do you require first-fill adherence interventions (phone counseling within 24 hours, nurse outreach, reminder SMS)? Options: Phone counseling within 24 hours, Nurse outreach, SMS reminders, No first-fill interventions
• Who will verify patient financial assistance eligibility and enroll patients into copay or manufacturer programs? Options: Your case management team, Third-party assistance provider, We handle enrollment, Shared responsibility

Dispense and ship specialty medications with cold chain

• Which cold-chain temperature ranges must be supported for your therapies (2-8°C, -20°C, frozen ship), and which products require them? Options: 2-8°C (refrigerated), -20°C (frozen), Ambient (no cold chain), Combination - list products
• How should temperature excursions be documented and reported (temperature log with timestamps, incident report to payer, automated alert)? Options: Temperature log with timestamps, Automated alert to stakeholders, Incident report with corrective action, All listed
• Specify the cold-chain packaging and validation artifacts you require at handoff (IQ/OQ validation of shipping containers, lot-level temperature validation).
• Do you require chain-of-custody documentation tied to member deliveries (signed delivery receipt, GPS-enabled timestamped scan)? Options: Signed delivery receipt, GPS-enabled timestamped scan, Photo proof of delivery, No
• What acceptance criteria will confirm successful cold-chain delivery for a batch (percentage of shipments within temp range, no excursions exceeding X hours)? Options: >= 98% shipments within temp range, >= 95% shipments within temp range, Custom threshold to define

Next-day fulfillment and trackable specialty shipping

• Which fulfillment window do you require for in-network deliveries (next-business-day, 48-hour, scheduled delivery)? Options: Next-business-day, 48-hour, Scheduled delivery window, No SLA
• How should tracking information be surfaced to your case teams and members (tracking number in portal, automated SMS, EHR message)? Options: Tracking in web portal, Automated SMS, EHR message to provider, Email to member
• Describe exceptions that should suspend next-day fulfillment (missing PA, incomplete insurance coverage, temperature-sensitive weekend delivery restrictions).
• Do you require performance SLAs for on-time fulfillment and delivery confirmation (e.g., 95% on-time delivery rate)? Options: Yes - specify target, No SLAs required, Custom SLA to negotiate
• What acceptance criteria will validate next-day fulfillment at go-live (on-time delivery rate, tracking visibility coverage percentage)? Options: >= 95% on-time delivery, >= 98% tracking visibility, Custom targets to define

Coordinate hospital discharge medication handoffs

• Which discharge workflows must be integrated (EHR discharge medication list, discharge prescription transmission, bedside counseling)? Options: EHR discharge med list, Electronic discharge Rx, Bedside counseling, Patient discharge packet
• How soon after discharge must the first supply be delivered to the patient or administered in facility (within 24 hours, 48 hours, other)? Options: Within 24 hours, Within 48 hours, Other
• Describe required handoff artifacts from the hospital (discharge summary, med administration record, list of inpatient therapies with start/end dates).
• Do you require bedside pharmacist counseling at discharge for certain therapies (Infusion meds, immunotherapies, high-risk biologics)? Options: Yes - for selected therapies, No, Optional based on case
• Who will own coordination with the hospital pharmacy and case managers for discharge medication continuity? Options: Your hospital case management, Hospital pharmacy team, Third-party care coordinator, Shared responsibility

Manage limited distribution drug access

• Which limited distribution manufacturer portals or specialty networks must we be authorized on to access therapies? Options: Manufacturer portal list to provide, Specialty network portals, Both, Not applicable
• How many products in your population are currently limited distribution and require special access workflows? Options: 1-5, 6-15, 16-50, 50+
• Describe required attestations or forms manufacturers request for limited distribution release (provider attestation, REMS forms, test result uploads).
• Do you require tracking of manufacturer authorizations and expiration dates for access (authorization expiry alerts)? Options: Yes - alerts required, No, Custom cadence
• When access is delayed by manufacturer approval, which interim support do you expect (bridge supply, alternate therapy routing, patient notification)? Options: Bridge supply, Alternate therapy routing, Patient notification only, Other

Manage copay and financial assistance enrollment

• Which financial assistance vehicles do your members commonly use (manufacturer copay card, foundation grants, patient assistance programs)? Options: Manufacturer copay card, Foundation grants, Patient assistance programs, Commercial copay accumulators
• How should copay assistance enrollment be validated and documented (copy of copay card, authorization number, completed enrollment form)? Options: Card image upload, Authorization number, Completed enrollment form, Automated verification via portal
• Describe income verification or eligibility artifacts required for foundation or manufacturer assistance.
• Do you require monitoring and reporting of copay assistance usage for member-level out-of-pocket exposure calculations? Options: Yes - include in reporting, No, Report summary only
• Who owns appeals or exceptions when copay assistance is denied or exhausted? Options: Your case management, We handle appeals, Shared process

Adherence monitoring and refill coordination

• Which adherence metric do you prioritize for specialty therapies (proportion of days covered PDC, medication possession ratio MPR, persistence at 6 months)? Options: PDC, MPR, Persistence at 6 months, Other
• How often should adherence data be collected and reported (daily feed, weekly summary, monthly report)? Options: Daily feed, Weekly summary, Monthly report, Quarterly
• Describe your preferred refill coordination rules for injectables and infusions (auto-refill, clinician confirmation, nurse coordination).
• Do you require automated outreach for missed refills (phone attempt, SMS, portal message) and after how many days? Options: Phone attempt after 3 days, SMS after 3 days, Portal message after 5 days, Custom cadence
• Are there member-level adherence thresholds that trigger care management escalation (e.g., PDC < 80% triggers nurse outreach)? Options: Yes - specify threshold, No thresholds defined, Custom escalation rules

Clinical counseling and side-effect management

• Which clinical roles should perform counseling for high-risk therapies (pharmacist, specialty nurse, clinician pharmacist practitioner)? Options: Pharmacist, Specialty nurse, Clinician pharmacist practitioner, Combined team
• How quickly must clinicians be able to reach a prescribing physician for urgent side-effect management (within 2 hours, same day, 24 hours)? Options: Within 2 hours, Same day, 24 hours, Asynchronous only
• Describe the clinical documentation you expect for counseling sessions (SOAP note, medication side-effect log, patient-reported outcome form).
• Do you require use of condition-specific patient-reported outcome instruments (e.g., A1c for diabetes, EDSS for MS) in counseling notes? Options: Yes - list instruments, No, Optional
• Are there mandated safety monitoring programs to integrate with (REMS, risk evaluation and mitigation strategies) for any covered products? Options: Yes - REMS required, No REMS, REMS for select products

EHR ePrescribing and clinical documentation integration

• Which EHR systems or interfaces must we integrate with for ePrescribing and clinical documentation (provide system names and endpoint types)? Options: EHR vendor details to upload, HL7 CDA interface, FHIR API endpoint, Direct messaging
• How should prior-authorization status and clinical notes be written back to the prescriber EHR (discrete fields, PDF attachment, structured FHIR resource)? Options: Discrete fields, PDF attachment, Structured FHIR resource, EHR-specific custom mapping
• Describe the security requirements for API credentials and EHR endpoint access (IP allowlist, OAuth2, client certificates).
• Do you require audit logs for all ePrescribing and documentation writes into the EHR (user, timestamp, action)? Options: Yes - full audit log, No audit log required, Selective logging
• Who will be the technical contact for EHR interface testing and certification on your side? Options: Your integration team, Vendor integrator, Clinical informatics lead, To be assigned

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Commercial Terms & Order Form
• Service Level Agreement (SLA)
• Data Processing Agreement (DPA) / HIPAA Business Associate Addendum (BAA)
• Integration & Data Access Addendum
• Governance and Escalation Plan

• Go-live Health Check (weeks 1-4)
• First Measurement Review (weeks 4-10)
• Acceptance Gate — Outcomes Acceptance (around day 90)
• Monthly Operational Review (ongoing)
• Quarterly Business Review (quarterly)

• Maintain a prioritized backlog of operational enhancements with clear next steps and timelines.
• Restate acceptance criteria and numeric targets
• Produce a documented pass or fail decision for each acceptance criterion recorded in the Service Scope stage.
• Capture a formal acceptance decision with named signatory for the buyer or record a remediation plan with target dates for any failed items.
• If applicable, confirm the incumbent system wind-down status and next steps to avoid dual-running.
• Publish the acceptance record showing pass/fail per criterion and, if accepted, archive it in the shared workspace.
• Create and publish remediation tasks for any failed acceptance criteria with verification steps and resolution dates.
• If incumbent wind-down applies, publish the legacy decommission checklist and target completion date.
• Monthly metric trends
• Ensure medication adherence rate and prior-authorization turnaround time remain on or are returning to trajectory toward Service Scope targets.
• Reduce open high-severity incidents and SLA exceptions by agreed percentage before the next review.
• Re-confirm success criteria and owners
• Publish the monthly outcomes pack showing metric trends, incident status, and backlog prioritization.
• Create discrete remediation tasks for all SLA exceptions with target resolution dates.
• Schedule technical fixes or reporting feed corrections identified during the data health check.
• Quarterly outcomes vs Service Scope targets
• Confirm whether quarterly medication adherence rate and patient satisfaction score meet the Service Scope targets or require focused remediation.
• Agree the top 3 improvement initiatives for the next quarter and record expected metric impact and delivery timeline.
• Ensure regulatory and fulfillment incidents are closed or have an approved remediation plan.
• Publish the quarterly outcomes report with therapy-area detail and the approved improvement plan.
• Create implementation tasks for the top 3 improvement initiatives with verification criteria and target dates.
• Compile a compliance closure report for any regulatory or fulfillment incidents that occurred during the quarter.
• Confirm each acceptance criterion recorded in the Service Scope stage has a named owner and an initial health status.
• List top 5 launch issues with remediation actions and target dates.
• Validate basic integration and fulfillment endpoints are passing smoke tests.
• Publish a deployment health summary that lists integration status, user onboarding rates, and open issues.
• Create remediation tasks for all high-severity launch defects with target resolution dates.
• Schedule the First Measurement meeting within the weeks 4-10 window.
• Present first measurement data
• Verify medication adherence rate and prior-authorization turnaround time measures are accurate and agree on their current trajectory against Service Scope targets.
• Document a corrective action plan with discrete tasks and target dates for any metric not on track.
• Confirm data sources and reporting feeds that will be used for the Acceptance Gate evaluation.
• Publish the validated metric extracts and calculation notes for adherence and PA turnaround to the shared workspace.
• Create remediation tasks for each root cause identified, with target completion dates and verification steps.
• Provide a timeline and list of deliverables required for the Acceptance Gate meeting.
• Deployment and integration validation
• Open incidents and SLA exceptions
• Present outcome data against each criterion
• Data quality and provenance check
• Therapeutic area and cohort analysis
• Enhancement and continuous improvement backlog
• Root-cause diagnosis for gaps
• Pass/fail determination per criterion
• Regulatory, compliance, and fulfillment incidents
• Early adoption and onboarding signals
• Agree corrective actions and timelines
• Formal acceptance decision and signatory capture
• Prioritized continuous improvement plan
• Data and reporting health
• Open defects and blockers
• Agree immediate remediation actions and next checkpoint
• Agree actions and ownerable tasks
• Quarterly executive summary and next steps
• Remediation plan for failed criteria
• Confirm path to Acceptance Gate
• Incumbent system wind-down review