Start Here: Tell Us About Your World

• Who are the people on your team we should know—titles, responsibilities, and who signs off on pharmacy changes?
• How many lives does this formulary/benefit design cover today? Options: Under 50,000, 50,000–499,999, 500,000–1,999,999, 2,000,000 or more
• Which model best describes how you currently purchase/manage pharmacy benefits? Options: Full-service PBM (traditional contract), Pass-through/transparent PBM, Vendor-managed formulary with carve-in/out, Self-administered with vendor partners, Other
• Who is your incumbent PBM or vendor today and when does your contract renew?
• What are the top three business goals driving your interest in exploring alternatives right now?
• Which of the following best describes the current executive priority for pharmacy cost initiatives? Options: Urgent—executive mandate this quarter, High—strategic priority this year, Medium—monitoring and opportunistic, Low—no immediate urgency

Are You Comfortable With the Numbers You're Being Told?

• What if your reported net PMPM is masking a fast-growing specialty cost — how confident are you that your numbers show the whole truth? Options: Extremely confident, Somewhat confident, Doubtful, Not confident at all
• What is your current overall net PMPM (or range) and how has it trended over the last 12–24 months?
• What percentage of total drug spend is specialty today, and how quickly is that percentage changing? Options: Under 20%, 20%–35%, 36%–50%, Over 50%
• Which therapeutic areas are driving the majority of your specialty spend right now? Options: Oncology, Autoimmune/Immunology, Hematology, Rare disease/Orphan, Hepatitis/CV/Diabetes, Other
• How frequently do you reconcile actual manufacturer payments vs. reported rebate credits? Options: Monthly, Quarterly, Semi-annually, Annually, Rarely/never
• When you look at your reconciliation process, where do you feel the most uncertainty—timing, granularity, auditability, or something else?

Who's Really Calling the Shots?

• What would happen to your implementation timeline if a clinical leader pushed back on a cost-saving formulary recommendation? Options: Timeline slips significantly, Minor delay, resolved internally, No impact, Unsure
• List the stakeholders (plan leadership, medical directors, employer sponsors, procurement, legal) and the decision each controls.
• Which of these stakeholders will need formal presentations or documented ROI to approve changes? Options: Pharmacy Director, Chief Medical Officer, Benefits/Compensation Lead, Finance/Controller, Procurement, Board/Trustees
• What is your internal timeline for a vendor decision and contract execution? Options: 30 days, 60–90 days, 3–6 months, 6–12 months, Undetermined
• What would success look like for each stakeholder group in the first 12 months (financial, clinical, operational)? Please be specific.
• Across plan, medical, and employer stakeholders, what are the top three risks you worry will derail this initiative?

Where Things Break Down — Tell Me the Stories

• Tell me about a recent patient or provider story where prior authorization, access, or specialty routing failed — what happened and why did it matter?
• How long does it typically take from a prior authorization initiation to final decision for specialty therapies? Options: Same day, 1–3 days, 4–7 days, 8–14 days, More than 14 days
• How do providers and members usually communicate frustrations to you, and how often do these complaints reach executive leadership? Options: Daily, Weekly, Monthly, Rarely, Never
• Which parts of your prior authorization workflow create the most manual work or error-prone handoffs? Options: Initial submission and documentation capture, Clinical review turnaround, Appeals and peer-to-peer, Member communications, EHR/Provider portal integration
• What percentage of prior auths for specialty drugs are ultimately approved, denied, or redirected to different therapies? Options: Mostly approved (>80%), Mixed (50–80%), Many denied or appealed (<50%), Don't track reliably
• How does it feel to your clinical team when throughput or denials spike—stress, burnout, defensiveness, or something else?

Are Rebates Helping—or Hiding the Problem?

• Could your current rebate structure be incentivizing higher list prices or shaping prescribing in ways that undermine net-cost goals? Options: Yes—likely, Possibly, Unlikely, No
• How are rebates currently contracted (pass-through, spread, guaranteed net, hybrid)? Options: Pass-through/Transparent, Spread pricing, Guaranteed net PMPM, Hybrid/Complex, Unsure
• How often do you receive line-level rebate detail tied to actual claims (not just lump-sum statements)? Options: Per claim/transaction, Monthly line-level, Quarterly aggregated, Annual summary, Never
• Have you ever conducted an independent audit of manufacturer remittances or PBM rebate accounting? If so, what surfaced?
• Which manufacturers or drug classes create the most complexity or dispute in rebate reconciliation?
• What transparency or contractual protections would give you real confidence in rebate flows?

If We Could Rebuild Your Formulary, What Would Change?

• Imagine your formulary actually nudged prescribers and members toward the lowest-net-cost clinically equivalent option—what's the single biggest barrier to that today?
• How is your formulary clinical governance structured (pharmacy & therapeutics committee frequency, membership, conflict-of-interest controls)?
• What percentage of formulary decisions are driven primarily by clinical evidence vs. financial incentives vs. provider preference? Options: Mostly clinical evidence, Balanced clinical and financial, Mostly financial, Mostly provider preference
• Where are you on biosimilar adoption for applicable therapies and what’s blocking faster uptake? Options: High adoption, Moderate, Low, Not using biosimilars
• Do you currently use step edits, indication-based tiering, or value-based contracting? Please specify which and how effective they are.
• If we proposed an evidence-based formulary change that reduced net cost but required a brief clinical exception pathway—how open would your medical leadership be? Options: Very open, Somewhat open, Hesitant, Not open

What Would ‘Success’ Actually Look Like in 6–12 Months?

• If you hit your target net PMPM reduction, but member complaints increased by 10%, would that be acceptable? Options: Yes, Maybe with mitigations, No, Depends on the nature of complaints
• Which of the following KPIs must move for you to call the project a success? Options: Net PMPM / total cost, Specialty spend as % of total pharmacy, Prior authorization turnaround time, Provider satisfaction, Member access measures, Rebate reconciliation accuracy
• What are your numeric targets or acceptable ranges for the top two KPIs (e.g., net PMPM reduction of X%, prior auth turnaround under Y days)?
• Which reporting cadence and format would help you feel in control—weekly operational dashboards, monthly executive summaries, or quarterly deep dives? Options: Weekly dashboards, Bi-weekly updates, Monthly executive summaries, Quarterly deep dives
• How will you verify clinical outcomes and member access are preserved while we chase cost improvements?
• What level of financial guarantees or shared-savings arrangements would you consider necessary to move forward? Options: Full guaranteed net, Partial guarantees with shared savings, No guarantees, outcome-based metrics only, Undecided

Data, Integrations, and Launch Readiness — How Close Are You?

• If we needed end-to-end claims and clinical data tomorrow, how many of these feeds are currently available and production-ready: pharmacy claims, medical claims, enrollment, lab results, provider directory? Options: All available and ready, Most available with minor work, Some available, significant work needed, Few or none available
• Which data formats or standards do you currently support for integrations? Options: X12 837/835/270/271, HL7/FHIR, CSV/SFTP, API-endpoints, Other
• Who owns integrations, security, and data governance on your side (names/roles) and how fast can they be mobilized?
• Do you have a provider-facing prior authorization portal today, and if so, how widely is it adopted? Options: Yes—widely adopted, Yes—limited adoption, No—manual processes, Planning to implement
• What security or compliance requirements (SOC2, HITRUST, BAAs, state regulations) must vendors meet before going live?
• What internal change-management resources (communications, training, provider outreach) can you commit to a deployment? Options: Dedicated team and budget, Some resources available, Minimal capacity, None—need vendor to lead

Small First Steps: What Would You Let Us Try?

• What's the smallest, least risky pilot you would approve that could prove value in 60–90 days? Options: A single therapeutic class, A subset of high-cost members, Rebate reconciliation audit, Prior authorization process redesign, Formulary tier change for a test cohort
• If we ran a pilot, which success signals would make you ready to scale (quantitative thresholds and qualitative feedback)?
• Who would need to sign off on a pilot and what approvals are required to begin?
• What governance cadence would you prefer for reviewing pilot progress—weekly ops calls, biweekly steering, monthly executive review? Options: Weekly ops, Biweekly steering, Monthly executive, Ad-hoc
• What are the most likely internal objections we should expect and who are the natural champions to help overcome them?
• If the pilot shows early wins, how quickly could you expand scope or approve a commercial agreement? Options: Immediately, Within 30 days, 30–90 days, Longer than 90 days

Final Check — Risks, Unsaid Concerns, and Next Steps

• What's the single thing you haven't told any vendor yet that would change the conversation if we knew it?
• Which risks keep you up at night about changing pharmacy partners—operational disruption, clinical quality, financial exposure, political resistance, or something else? Options: Operational disruption, Clinical quality, Financial exposure, Political/resistance, Other
• What would you need from us in the next 7 days to feel this discovery was worth your time? Options: A tailored ROI model, Detailed project plan, References and case studies, A short pilot proposal, Security/compliance docs
• Who else should join our next conversation to make progress and what would you like that meeting to achieve?
• If we capture everything discussed and propose a focused next step, how would you prefer we deliver it—slide deck, live walkthrough with your data, or a brief written plan? Options: Live walkthrough with data, Slide deck and Q&A, Concise written plan, Other

Start with the Paper Trail

• To get us going: which single document or report best summarizes your current formulary and contracting setup? Options: Formulary policy PDF, Master rebate schedule, Claims summary report, Prior authorization SOP, No single source, Other
• Walk me through how a new specialty drug typically gets from evaluation to coverage on your formulary — who touches it and in what order?
• Which internal teams regularly update or approve formulary or clinical rules? Options: Pharmacy operations, Medical affairs, Clinical pharmacy team, Medical director, Finance/strategy, Legal/compliance, Other
• How often do you publish formal formulary changes (e.g., quarterly, ad hoc)? Options: Monthly, Quarterly, Biannually, Annually, Ad hoc / as-needed
• Who is your single point of contact for clarifying coverage decisions during vendor conversations?

Where Money Disappears (and Why You Might Not Know)

• When you trace net drug spend from gross ingredient cost to net PMPM, where are you most uncertain about the numbers? Options: Manufacturer rebates, Clinical rebates/adjustments, Specialty pharmacy fees, Direct and indirect remuneration (DIR), Provider-admin fees, Other
• How do rebate flows move from manufacturer to payer in practice — direct payment, pass-through, aggregated remittance, or opaque reconciliations? Options: Direct to plan, Pass-through to plan, PBM-retained with reconciliations, Manufacturer clawbacks, Combination / hybrid, Not sure
• Give an example of a recent reconciliation or audit finding that surprised you — what was the issue and impact?
• How frequently do you reconcile rebates to claims and what percentage of reconciliations require manual adjustments? Options: Monthly, Quarterly, Annually, Ad hoc, No reconciliations
• Which parts of the rebate lifecycle feel most opaque or risky to your finance team? Options: Contract terms/definitions, Measurement and attribution, Timing of remittances, Auditability, Data integrity, Other

The Prior Auth Bottleneck — Who’s Really Getting Through?

• Roughly what percentage of specialty prescriptions go through prior authorization today? Options: <10%, 10–25%, 26–50%, 51–75%, >75%, Unsure
• When prior auth decisions are delayed, where is the harm felt most — patient adherence, provider churn, avoidable medical spend, or something else? Options: Patient adherence, Provider satisfaction/complaints, Medical spend (e.g., hospital/ER), Pharmacy leakage, Other
• Describe your current prior authorization workflow from submission to decision — include tech platforms, average turnaround, and human handoffs.
• Which of these best describes your prior auth operations today? Options: Fully manual with phone/fax, Hybrid (portal + manual review), Automated rules with human override, Third-party vendor handles most reviews, Not standardized
• What are the top three reasons authorizations are appealed or escalated? Please give concrete examples.

Specialty Channels: Who’s Actually In Control?

• If I asked you: 'Are specialty pharmacy channels driving quality access or increased cost?' which half of that sentence feels more true for you today — and why? Options: More quality access, More increased cost, Balanced, Unsure
• Which specialty fulfillment model do you primarily use? Options: Plan-owned specialty, PBM-owned specialty, External network specialty, Limited-home infusion partnerships, Multiple models / hybrid
• How often do members use out-of-network specialty pharmacies, and what are the typical drivers? Options: Rarely, Occasionally, Often, Very often, Unsure
• What controls do you have to route claims to preferred specialty channels (e.g., step edits, mandated dispensing site)?
• Share a recent case where specialty channel choice materially affected cost or clinical outcome — what happened and what would you change?

Formulary Logic: Comfortable or Compromised?

• Do your current formulary tiering and utilization management rules consistently steer members toward the lowest-net-cost clinically equivalent option? Options: Yes, consistently, Mostly, Sometimes, Rarely, Never
• How are clinical equivalence and therapeutic interchange decisions made and documented? Options: Clinical committee with minutes, Clinical team guidance, Vendor-provided rules, Ad hoc judgment by pharmacists, Not consistently documented
• What percent of high-cost specialty fills could have been routed to a therapeutically equivalent lower-cost product (e.g., biosimilar) in the last 12 months? Options: <10%, 10–25%, 26–50%, 51–75%, >75%, Unknown
• Where do you see the biggest tension between clinical guidance and financial steering in your formulary decisions?
• If you could change one formulary rule or tier tomorrow, what would it be and why?

Rebates: Transparent Partnership or Black Box?

• Tell me honestly: when you look at rebate contracts, do you feel confident you’re capturing the full financial value for your members? Options: Completely confident, Mostly confident, Somewhat confident, Not confident, I don’t review contracts
• Which rebate structures apply across your top 10 drugs by spend? Options: Fixed per-unit rebate, Performance-based rebates, Market-share/volume rebates, Flat percentage, No rebates, Combination
• How are rebate liabilities and receivables modeled into your PMPM forecasts and budgets? Options: Included in PMPM forecast, Modeled separately, Not modeled reliably, Finance handles ad hoc
• Have you experienced delays or shortfalls in expected rebate payments? If yes, describe impact and frequency. Options: Yes - frequent, Yes - occasional, Rarely, Never, Unsure
• What visibility or reports would make rebates feel auditable and reliable to your team?

Data Plumbing: Can You Trust What You're Seeing?

• If a cost or utilization number looks wrong, how long does it take you to get a trustworthy answer? Options: Same day, 1–3 days, 1–2 weeks, More than 2 weeks, Never get a reliable answer
• Which data feeds do you currently have into your analytics environment? Options: Real-time claims, Pharmacy claims batch, Medical claims, Rebate remittance files, Prior auth logs, Provider feedback, Other
• What percentage of your formulary/rebate/prior auth decisions are informed by linked member-level claims versus aggregated reports? Options: Nearly all (90%+), Majority (60–89%), Some (25–59%), Rarely (<25%), Never
• Describe a time data quality undermined a decision — what went wrong and how did you detect it?
• Which data permission or access constraints slow down your ability to analyze savings/opportunity? Options: PHI restrictions, Vendor contract limits, Technical ingestion delays, Lack of IDs to link files, Internal governance approvals, Other

Frontline Frictions: Provider and Member Voices

• How often do providers call or complain about prior authorization complexity, and what do they typically ask for? Options: Daily, Weekly, Monthly, Rarely, Never
• When members abandon prescriptions, do you have a consistent way to capture why — cost, access, confusion, or clinical reasons? Options: Yes - standardized reason codes, Partially captured, Anecdotal only, We don’t capture abandonment reasons
• What feedback channels exist from providers and members back into formulary or prior auth design? Options: Provider portal comments, Member surveys, Support center logs, Advisory panels, None
• Share a story where frontline feedback led to a policy change — what changed and how did outcomes improve?
• Which stakeholder complaints do you feel most pressure to resolve quickly (e.g., C-suite, providers, large employer groups)? Options: C-suite/finance, Medical Director/CMO, Large employer clients, Provider networks, Member advocacy groups, Regulators

Small Wins That Point to Bigger Levers

• What recent small change (rule tweak, routing change, vendor tweak) produced outsized savings or fewer complaints?
• Which operational change could be implemented in 60–90 days with minimal risk but likely measurable upside? Options: Formulary tier change, Prior auth criteria simplification, Route-to-preferred specialty, Add biosimilar default, Rebate contract renegotiation, Data reconciliation automation
• If you had one dedicated analyst or project manager for 3 months, what would you task them to investigate first?
• Who needs to be convinced internally for that short pilot to proceed, and what objection do you expect from them?
• Finally, what success signal would make you say 'this is working' after a 3-month experiment (use concrete metrics if possible)? Options: Net PMPM reduction, Reduction in prior auth turnaround time, Increase in biosimilar adoption rate, Decrease in member complaints, Improved rebate realization, Other

Starting Together: A Quick Snapshot

• What's your title and the approximate population you manage (commercial lives / Medicare / Medicaid / ASO)? Options: Pharmacy Director, Chief Medical Officer, Benefits VP/Director, Other
• What are the top 1–2 priorities for your pharmacy/benefits organization in the next 12 months? Options: Reduce net PMPM, Improve prior auth turnaround, Increase biosimilar adoption, Increase rebate transparency, Improve member/provider experience, Other
• How would you describe your current relationship with your PBM(s) or vendors right now—mainly stable, fraying, or in transition? Options: Stable / highly functional, Some friction but manageable, Fraying / trust issues, Actively transitioning or RFP in flight
• When you think about a successful partnership, which single outcome matters most to you personally? Options: Measured reduction in net PMPM, Fewer provider/member complaints, Faster prior auth turnaround, Clear, auditable rebate reporting, Improved clinical outcomes, Other
• Tell us one recent win or one recent pain point that captures how your pharmacy program feels today.

If You Could Turn the Tide Tomorrow, What Would Be Different?

• Right now, what’s the one result you would trade everything else for if it meant solving it within 6 months? Options: X% net PMPM reduction, Eliminate specific rebate leakage, Cut prior auth turnaround by Y hours/days, Achieve Z% biosimilar conversion, Other
• What specific financial and clinical targets would make you say the engagement was an unqualified success?
• Which stakeholders must be visibly satisfied for this to count as success (select all that apply)? Options: Pharmacy Director, CFO/Finance, Chief Medical Officer, Employer Benefits Lead, Member Experience/Call Center Lead, Legal/Compliance
• How would you like success to be measured and reported (frequency and format)? Options: Monthly dashboard, Quarterly executive review, Real-time KPI portal, Ad-hoc deep-dive reports, Other
• If we achieved the financial targets but created marginally more provider work, would you consider that acceptable, or is provider burden a hard stop? Options: Acceptable if net savings significant, Acceptable with mitigation plan, Hard stop—provider burden cannot increase, Unsure

Where the System Is Leaking Money and Trust

• Which area feels most like a recurring source of waste, error, or frustration—formulary design, rebate reconciliation, prior auth, specialty pharmacy, or something else? Options: Formulary design, Rebate reconciliation, Prior authorization, Specialty pharmacy/channeling, Claims adjudication, Other
• Can you give a concrete example (recent case or metric) where that problem cost you money or created member/provider escalation?
• How confident are you in the accuracy and auditability of rebate flows and manufacturer payments today? Options: Very confident, Somewhat confident, Doubtful, We have no visibility
• How often do prior auth delays lead to appeals, ER visits, or provider churn in your experience? Options: Frequently (weekly), Often (monthly), Occasionally (quarterly), Rarely/Never
• Which drug categories drive the majority of your volatility and why (select all that apply)? Options: Oncology, HIV/Antivirals, Autoimmune/TSB, Specialty biologics, High-cost generics, Biosimilars, Other
• How does this friction feel internally—annoying, urgent, politically risky, or existential? Options: Annoying/operational, Urgent/needs action, Politically risky, Existential/major financial risk

Assumptions We're Both Making — Which Are Wrong?

• What conventional wisdom about your PBM or the market do you suspect is wrong but haven’t had the space to test?
• Which of these do you assume is true about your current arrangement: rebates equate to net savings, prior auth is mostly clinical, specialty routing is optimized, or something else? Options: Rebates = net savings, Prior auth is primarily clinical, Specialty routing maximizes value, Claims adjudication is unbiased, Other
• How often do vendor contracts or PBM practices force trade-offs you privately disagree with (e.g., clinical vs. financial priorities)? Options: Always, Often, Sometimes, Rarely, Never
• If we challenged one long-held assumption together, which one would you want us to examine first and why?
• How comfortable are your internal stakeholders with surfacing uncomfortable truths about vendor performance? Options: Very comfortable, Somewhat comfortable, Hesitant, Not comfortable at all

What Would Success Actually Feel Like for Your Team and Members?

• Imagine it’s 12 months after go-live and you’re presenting results—what anecdote would you tell that proves we got it right?
• Which member or provider experience improvements would matter most to your executives (select up to 2)? Options: Faster prescriptions filled, Fewer appeals, Clearer communications, Lower out-of-pocket cost, Fewer therapy interruptions, Other
• What are the minimum quantitative thresholds (e.g., net PMPM, prior auth turnaround, biosimilar uptake) that would make you confident to expand the program?
• Beyond numbers, what cultural or political signals would tell you this partnership is trusted and sustainable?
• Which executive will sign off on expansion when those thresholds are met, and what do they care about most? Options: CFO/Finance, Chief Medical Officer, Head of Benefits/HR, CEO/President, Board/Trustees, Other

Roadblocks You Can See Today — And the Ones You’re Not Saying

• What internal obstacles (IT, legal, procurement, unions, budget cycles) are most likely to delay launch? Options: IT/data access, Legal/contracting, Procurement/RFP timing, Budget cycle/fiscal year, Stakeholder alignment/politics, Other
• How ready are your systems to deliver the data we’d need for an accurate model and verification (claims, enrollment, PBM remits, rebate statements)? Options: Fully ready, Mostly ready with cleanup, Partial—significant work needed, Not ready
• Who would need to be our day-to-day data or operations partner inside your organization, and how available are they right now?
• What political or vendor relationships could quietly block changes even if technical and financial cases are strong?
• On a scale from 1–10, how much change fatigue exists across your stakeholders—and where does that fatigue show up most? Options: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10

First Small Commitments That Change the Game

• If we proposed a low-risk proof of value, what's the smallest scope that would meaningfully convince your leadership? Options: PMPM modeling + savings estimate, Prior auth turnaround pilot, Rebate reconciliation audit, Biosimilar routing pilot, Claims accuracy validation
• What data would you be willing to share for a pilot, and what approval or NDAs would we need to get started? Options: De-identified claims, Full adjudicated claims, Rebate statements, Enrollment files, Prior auth logs, Other
• Who must be the named owner on your side for a pilot to proceed, and who should we copy into governance calls?
• What timeline feels realistic for a 6–12 week pilot to surface credible signals (data handoff → analysis → validation)? Options: 4–6 weeks, 6–8 weeks, 8–12 weeks, Longer than 12 weeks
• Which acceptance criteria would let you greenlight expansion after the pilot (select up to 3)? Options: Net PMPM reduction threshold, Improved prior auth SLA, Rebate recovery verified, Provider satisfaction improvement, Claims accuracy within tolerance, Other
• What would make you hesitant or say no after a pilot, even if numbers look promising?

Start Here: Tell Us About Your World

• Which role best describes the person answering these questions? Options: Pharmacy Director (Health Plan), Chief Medical Officer, VP/Director of Benefits (Employer), Finance/Actuarial Lead, Other
• How many covered lives does this pharmacy benefit manage? Options: <50,000, 50,000–250,000, 250,000–1M, 1M–5M, >5M
• Briefly describe your benefit type and population mix (commercial, Medicare Advantage, Medicaid, ASO employer mix, clinical risk populations).
• Which PBM functions are currently handled by your incumbent (select all that apply)? Options: Formulary design/management, Rebate contracting and reconciliation, Claims adjudication, Prior authorization administration, Specialty pharmacy management, Clinical programs (MTM, DUR), Member/provider communications, Analytics and reporting, None of the above
• What is the single most important pharmacy outcome your leadership expects this year? Options: Reduce net PMPM, Slow specialty spend growth, Improve prior auth turnaround, Increase biosimilar adoption, Improve member access/satisfaction, Other

Where the Money Is Slipping Through the Cracks

• Looking at the last 12 months, what percentage of pharmacy spend do you believe is avoidable through better formulary design or rebate strategy? Options: <2%, 2–5%, 5–10%, 10–20%, >20%
• Which three drug classes or molecules have been the biggest drivers of unexpected spend or volatility for you? Options: Oncology (injectable), Oncology (oral), Hepatitis C, Immunology/Biologics, Rare disease therapies, Specialty endocrine, CAR-T and gene therapies, Other
• Give a concrete example of a recent contract, rebate, or formulary outcome that surprised you—and describe the impact it had on net cost or member access.
• How confident are you in the accuracy and timeliness of rebate reconciliation from your current vendor? Options: Completely confident, Mostly confident with occasional issues, Unsure / mixed signals, Not confident
• When reconciliation issues arise, how long do they typically take to resolve and who owns escalation?
• How does uncertainty or opacity in rebate flows affect conversations with finance or executive leadership?

When Processes Break: The Hidden Friction

• How often do prior authorization or specialty access issues lead to delayed care or member/provider complaints? Options: Daily, Weekly, Monthly, Quarterly, Rarely/Never
• What is your target prior authorization turnaround time (hours/days), and what is your measured average today?
• Approximately what share of prior authorizations are handled automatically vs require manual clinician review? Options: >80% automated, 50–80% automated, 20–50% automated, <20% automated, Don't know
• Describe a recent workflow or IT gap that created operational friction (e.g., claims overrides, PA portal downtime, specialty fulfillment errors). What was the downstream impact?
• Who inside your organization is most impacted by these breakdowns (e.g., provider relations, case management, call center), and how does it feel for them when it happens?
• What is the typical volume and type of appeals or complaints you escalate to your PBM, and how satisfied are you with their responsiveness? Options: Very satisfied, Somewhat satisfied, Neutral, Somewhat dissatisfied, Very dissatisfied

Are Your Incentives Really Aligned?

• If your vendor's reported savings came primarily from rebate timing and not lower net cost, would that feel like a meaningful win to your CFO? Options: Yes — savings are savings, Partially — depends on transparency, Not really — we need durable net cost reduction, Unsure
• Which of the following best describes your current commercial model with your PBM? Options: Pass-through with fixed admin fee, Pass-through with % fee, Spread pricing, Shared savings/performance-based, Capitated/at-risk, Other
• What level of rebate and fee transparency would you require to feel comfortable (select one)? Options: Line-item pass-through with monthly detail, Quarterly summarized reports with drill-down, Real-time dashboards with audit access, High-level reconciliations only
• Have you had formal disputes or audit findings with your PBM in the past 24 months? If yes, what was the root cause? Options: No disputes, Rebate reconciliation discrepancies, Claims pricing errors, Contract interpretation, Data/reporting gaps, Other
• How frequently does your executive governance team review PBM performance and financials? Options: Monthly, Quarterly, Semi-annually, Annually, Ad hoc / only when problems arise
• How do these contracting structures make you feel about the prospect of a long-term partnership with your PBM?

Imagine the One Number That Changes Everything

• Which single metric, if improved by 10%, would make leadership declare the program a success? Options: Net PMPM, Specialty spend as % of total drug spend, Prior authorization turnaround time, Biosimilar adoption rate, Member out-of-pocket costs, Net drug spend variance vs budget
• Pick up to three metrics you actively track today (select up to three). Options: Rebate yield, Net PMPM, Gross drug spend, Specialty % of spend, Prior auth TAT, Appeals/overturn rate, Biosimilar penetration, Member satisfaction (NPS)
• For the top metric you selected, what is your current baseline and what is your stretch target over 12 months?
• What evidence or data would you need to feel confident a proposed solution achieved the target (e.g., 6 months of validated claims, third-party audit, member outcomes)? Options: Validated claims run, Third-party reconciliation audit, Pilot with live members, Provider feedback batch, Other
• Who in your organization must sign off on acceptance criteria (roles, not names)? Options: CFO/Finance, Chief Medical Officer, Pharmacy Director, Legal/Contracts, Employer Benefits Lead, IT/Data Security

What Would True Operational Readiness Look Like?

• If we asked you to run a full cutover simulation this month, how confident are you that data feeds, provider directories, and claims mapping would be ready? Options: Very confident, Mostly confident with minor gaps, Somewhat confident, Not confident
• Which data feeds and integrations are non-negotiable for go-live (select all that apply)? Options: Real-time claims feed, Eligibility/Membership, Prescriber NPI and taxonomy, Rebate contract files, Prior auth decision feed, Specialty fulfillment feeds, Provider portals, Other
• What percentage of historical claims would you expect us to validate pre-go-live to feel comfortable (e.g., 1%, 5%, 10%, more)? Options: <1%, 1–2%, 3–5%, 5–10%, >10%
• Describe any security, privacy, or compliance requirements that would block data sharing or integrations unless addressed (e.g., SOC2, HIPAA BAAs, state-specific regs).
• Who will be the operational owners on your side for cutover, testing, and post-go governance?
• How do you prefer testing be structured: phased pilot by population, parallel run, or full cutover simulation? Options: Phased pilot by population, Parallel run with live claims, Full cutover simulation, Other

Deciding to Change: Risks, Timing, and Commitments

• What is the single biggest risk that would stop this change from moving forward, and why would it be fatal?
• When is your current contract renewal window or earliest practical cutover date? Options: Within 3 months, 3–6 months, 6–12 months, >12 months, No fixed window
• Which internal stakeholders will be most resistant to change and what are their main concerns?
• How important is a pilot or phased approach to your decision process? Options: Critical — must pilot before committing, Helpful but not required, Neutral, Prefer direct transition
• What contractual features or commercial protections would reduce your perceived risk (select up to three)? Options: Performance guarantees tied to KPIs, Escrows or clawbacks, Third-party reconciliation audits, Short initial term with exit clauses, Pilot with defined acceptance, Transparent pass-through accounting
• If we proposed a 90-day proof-of-value focused on one metric you care about, which metric would you choose and why?
• Realistically, what internal timeline would you need to make a decision after seeing pilot results? Options: Immediately after pilot, 2–4 weeks, 1–2 months, >2 months