A quick snapshot of your world

• Tell me briefly about your role, the lives you manage, and the pharmacy scope you own
• How many covered lives does your main pharmacy benefit plan include? Options: Under 50,000, 50,000 to 250,000, 250,000 to 1M, Over 1M
• Which formulary management model do you operate today Options: Pass-through PBM with traditional formulary, Integrated pharmacy and medical management, Carve-in medical spend separately, Self-managed formulary, Other
• When was the last time you changed major formulary rules, and what triggered that change
• Estimate your current annual specialty drug cost trend for the plan Options: Flat or down, 0% to 5% increase, 6% to 15% increase, Over 15% increase, Unsure

Where the pressure shows up in your budget

• If specialty spend kept growing at the current rate for another year, which budget line or program would you cut first Options: Care management programs, Behavioral health, Provider reimbursement, Member benefits, Other
• Who on your team feels the most day-to-day strain from rising specialty costs Options: Pharmacy director, Finance lead/CFO, Medical director, Benefits/HR lead, Operations manager, Other
• How often do provider or member complaints about prior authorization processes reach executive leadership Options: Weekly, Monthly, Quarterly, Rarely, Never
• Describe a recent example where rebate timing or remittance created a material reporting or cash-flow problem for you
• Which of these outcomes would change how leadership views your pharmacy strategy this year Options: Lower net drug cost PMPM, Faster prior authorization turnaround, Higher biosimilar uptake, Clearer rebate reporting, Improved provider satisfaction
• Which metric, if missed next quarter, would trigger a formal program review in your organization Options: Net drug cost PMPM, Specialty spend growth rate, Prior authorization turnaround time, Biosimilar adoption rate, Provider complaints

Where your current processes fall short

• If your prior-authorization and specialty workflows suddenly failed for a week, what downstream problem would materialize first Options: Higher member out-of-pocket, Delayed patient starts, Claims denials spike, Provider escalation to leadership, Other
• Which part of your formulary update cycle feels manual or brittle today Options: Clinical review and evidence synthesis, Tier assignment and pricing, Stakeholder approvals, File distribution to payers/providers, Other
• How transparent is your current rebate reconciliation, on a scale from clear to opaque Options: Fully transparent and auditable, Mostly transparent with some gaps, Opaque for significant line items, We do not receive regular reconciliation
• When a biosimilar could lower net cost, where does the project typically stall Options: Clinical adoption plan, Provider education, Rebate dynamics, Contracting/legal, Member communications
• Tell me about the last time a vendor or internal change produced worse-than-expected clinical or financial results, what went wrong
• Which single operational failure would make you pause a new vendor selection immediately Options: No secure claims feed available, No named owner for implementation, Lack of API for prior-authorization portal, Insufficient compliance evidence

The alternatives you are actively weighing

• Which options have you evaluated or are still considering for managing specialty and rebate complexity Options: Stay with incumbent PBM, Switch to a pass-through PBM, Contract with integrated specialty manager, Build capability internally, Other
• Has anyone proposed solving these problems with an internal build instead of a partner, and who champions that idea Options: Yes, IT, Yes, Pharmacy Clinical Team, Yes, Finance, No internal build proposed, Unsure
• Which evidence would convince you to stay with your current approach rather than change vendors Options: Clear year-over-year net cost savings, Improved PA turnaround metrics, Demonstrated biosimilar uptake, Full rebate transparency and audit access, All of the above
• How recently have you issued an RFP or run a formal vendor review for these services Options: Within 3 months, 3 to 12 months, Over 12 months, Never
• What single condition would make you keep your incumbent even if alternatives promised better pricing Options: Immediate proof of rebate transparency, Named operational owners and timeline, No disruption to member access, Lower total cost of care within 6 months

If you had a clear win, how would you measure it

• If you could reduce net specialty drug cost by 15% in 12 months, what would you do with the budget savings Options: Expand care management, Lower member premiums, Invest in other clinical programs, Return to plan sponsor, Other
• Which of these success signals matters most to your board or executive team Options: Net drug cost PMPM, Prior-authorization turnaround, Biosimilar adoption rate, Rebate cash-flow predictability, Provider satisfaction
• How quickly do you expect to see measurable movement on those signals if a new program is implemented Options: Within 3 months, 3 to 6 months, 6 to 12 months, Longer than 12 months
• Which acceptance criteria would make a pilot successful enough to expand system-wide Options: X% net cost reduction, Y% faster PA turnaround, Z% increase in biosimilar fills, Full reconciliation within 30 days
• If the pilot meets your top success signal, what internal approvals would be required to sign a full contract that week Options: CFO approval, Medical director sign-off, Procurement and legal, Board or executive committee

Operational readiness and technical constraints

• Which of these data feeds are currently available to share for an implementation Options: Real-time claims feed, Daily claims batch, Formulary files, Prior-authorization logs, Rebate ledgers
• Who owns the API or file endpoints the deployment will need, and are they authorized to grant access Options: Internal IT owns and can grant access, Third-party vendor owns and can grant access, No current owner identified, Unsure
• How much engineering bandwidth can you dedicate to integrations in the first 90 days Options: Dedicated team available, Partial support from IT, Minimal support, need vendor-led work, No internal capacity
• Do you have named owners and SLAs for claims file delivery and prior-authorization portal access Options: Yes, named owners and SLAs, Named owners but no SLAs, No named owners
• Which regulatory or compliance approvals could delay go-live Options: Finance audit, Legal contract review, State regulator notice, Privacy/security review, None identified
• Which single technical or compliance gap would stop the project from starting on your target date Options: No secure claims feed, No PA portal access, Incomplete rebate data, Pending legal approval

Deal dynamics and decision timeline

• Who are the decision makers that must sign off to move from pilot to full contract Options: Pharmacy director, CFO, Medical director, Procurement, Benefits lead, Other
• Which internal metric or event would accelerate the buying decision in the next 90 days Options: Budget reforecast, Executive review flagged risk, Regulatory change, Vendor demonstration success, Other
• If a vendor can demonstrate your primary success signal in a pilot, what internal approvals would be needed to sign within two weeks Options: CFO and legal only, Executive committee plus legal, Full procurement process required, Other
• How flexible is your desired contract term and pricing structure Options: Open to outcome-based pricing, Prefer fixed term with reconciliation, Must be traditional fee model, Undecided
• What single business outcome would make leadership push this project to the top of the priority list Options: Immediate PMPM savings, Provider satisfaction improvement, Regulatory compliance benefit, Operational efficiency

Practical next steps and owners

• Who would be the day-to-day point of contact for implementation and integrations Options: Pharmacy operations manager, IT integration lead, Project manager, Clinical program manager, Other
• Which artifacts can you share in the next two weeks to speed scoping Options: Latest formulary file, Claims sampling file, PA rules export, Rebate ledger, None available
• How soon can your team commit to a technical scoping session Options: Within 1 week, 1 to 2 weeks, 3 to 4 weeks, Longer than 4 weeks
• What would have to change internally for you to be ready to run a pilot within 60 days Options: Named owners in place, Claims feed available, Budget approved, Legal terms pre-agreed
• Are there any holidays, contracting blackout periods, or fiscal milestones we should avoid when planning go-live Options: Yes, No, Unsure
• If the pilot validated your primary success signal, what would be the single next decision that accelerates full roll-out Options: Executive sign-off, Budget release, Procurement approval, Contract signature

• Solution Experience — Formulary and Specialty Workflows

• Confirm the current state and its cost
• You confirm the demonstrated workflow eliminates the manual reconciliation steps and produces an auditable rebate reconciliation tied to claims.
• Run a sample net-cost model using the provided 12 months of de-identified specialty claims and deliver projected net PMPM and savings by therapeutic class.
• Walk an end-to-end formulary-to-claim workflow
• You confirm the demonstrated prior-authorization flow meets your expected turnaround improvements and will reduce provider complaints.
• Prepare an auditable rebate reconciliation example that maps manufacturer remittances to claims adjustments for the scenario reviewed.
• Prove rebate pass-through and reconciliation
• Provide 12 months of de-identified specialty claims, current rebate schedules, and your current PA turnaround targets to enable the sample model and reconciliation.
• You agree on which evidence remains required to finalize scope and commercial terms, for example a claims-backed net-cost model and a test reconciliation.
• Confirm the biosimilar adoption target and the primary stakeholders who will validate clinical equivalency and provider communications.
• Demonstrate the prior-authorization and specialty channel improvements
• Quantify biosimilar adoption impact
• Validate that this matches your needs

• Solution Experience — Formulary and Specialty Workflows
• Solution Experience Deck
• Solution Brief

• meeting
• slides
• document

• Implement Formulary Tiering and Updates
• Execute New Drug Formulary Additions and Edits
• Negotiate and Administer Manufacturer Rebate Contracts
• Reconcile and Report Rebate Pass-Throughs
• Operate Pharmacy Claims Adjudication and Payments
• Integrate Claims Platform with Buyer Claims Feed
• Deploy Provider Prior Authorization Portal
• Operate Prior Authorization Adjudication and Appeals
• Operate Specialty Pharmacy Dispensing and Fulfillment
• Operate Specialty Pharmacy Clinical Case Management
• Deploy Biosimilar Adoption and Transition Program
• Deliver Drug Utilization and Cost Analytics
• Operate Member Pharmacy Engagement Tools

Implement Formulary Tiering and Updates

• Which formulary file format do you require for tier updates (NCPDP-formulary CSV, FHIR Formulary, custom CSV/Excel)? Options: NCPDP-formulary CSV, FHIR Formulary (FHIR R4), Custom CSV/Excel, Other (describe)
• How often must tiering updates be applied to your live formulary (immediate upon approval, daily, weekly)? Options: Immediate upon approval, Daily, Weekly, Custom cadence
• Who in your team signs off on tier changes and where should approvals be captured (signed PDF, ticket ID, change log entry)?
• Specify the acceptance criteria that will confirm final tier configuration (for example: matched drug list count, zero unmatched NDCs, tier mapping accuracy %) .
• Do you require automated audit trails for tier changes with user, timestamp, and change reason captured? Options: Yes, No

Execute New Drug Formulary Additions and Edits

• When a new drug review is requested, which supporting documents must accompany the request (FDA label, AMCP dossier, clinical guideline excerpts)? Options: FDA label, AMCP dossier, Clinical guideline excerpts, Other (describe)
• Identify where the new drug record should be staged for review (pharmacy clinical review queue, medical policy queue, P&T committee packet). Options: Pharmacy clinical review queue, Medical policy queue, P&T committee packet, Other (describe)
• Describe how therapeutic equivalents and biosimilar alternatives should be presented in the addition record (mapped NDCs, preferred product flag, substitution policy note). Options: Mapped NDCs, Preferred product flag, Substitution policy note, Other (describe)
• Do you require automatic crosswalk of a newly added drug to your existing tier and copay structures? Options: Yes, No
• Provide the maximum turnaround time you expect between final formulary decision and posting to claims adjudication (in business days). Options: 1 business day, 3 business days, 5 business days, Custom

Negotiate and Administer Manufacturer Rebate Contracts

• What rebate structures are in scope for negotiation (per-unit rebate, gross-to-net chargeback, percentage of WAC)? Options: Per-unit rebate, Gross-to-net / chargeback, Percentage of WAC, Other (describe)
• Who will be the contract negotiation contact and who on your team holds signature authority for rebate agreements?
• Define the audit rights and frequency you require for rebate contracts (for example: quarterly ledger review, annual third-party audit). Options: Quarterly self-audit, Annual third-party audit, Monthly reconciliations, Other (describe)
• Are there existing master rebate agreements or templates we must ingest; if so, will you provide redacted samples? Options: Yes, will provide samples, No
• Specify any minimum guaranteed rebate thresholds or recoupment clauses that must be preserved in scope.

Reconcile and Report Rebate Pass-Throughs

• Select the remittance reporting format you require for pass-throughs (transaction-level CSV, summarized ledger, ERA/835 mapping). Options: Transaction-level CSV, Summarized ledger, ERA / EDI 835 mapping, Other (describe)
• Indicate how frequently you require pass-through reconciliation reports (monthly, quarterly, real-time dashboard). Options: Monthly, Quarterly, Near real-time dashboard, Other (describe)
• Identify the owner on your side who will accept reconciliation results and list the evidence you need to validate rebate allocations (for example: remittance file, matched NDC-level claims).
• List any patient-level de-identification or PHI masking rules that must be applied before rebate reports are delivered. Options: Remove all PHI, Tokenize member IDs, Deliver only aggregated data, Other (describe)
• Provide the tolerance threshold for reconciliation variances that will trigger investigation (dollar amount or percentage). Options: $0, < $1,000, < 0.5%, Custom (describe)

Operate Pharmacy Claims Adjudication and Payments

• Select the claim formats we must support for adjudication and routing (NCPDP Telecommunication Standard, EDI 837, batch flat file). Options: NCPDP Telecommunication Standard (real-time), EDI 837 (batch), SFTP flat file, Other (describe)
• Map the BIN/PCN/Payer ID values and any adjudication field mapping requirements we should configure for your plan.
• Indicate whether you require real-time benefit checks and copay accumulator logic during adjudication. Options: Yes, No
• Choose your desired claim turnaround SLA for real-time transactions (for example: response within 1 second). Options: < 1 second, 1-3 seconds, > 3 seconds, Batch next-day
• List the recipients for remittance advice (EDI 835) and describe how ERA fields should map to your accounting ledger.

Integrate Claims Platform with Buyer Claims Feed

• Confirm the feed delivery method you will use for paid pharmacy claims (SFTP flat file, API push with TLS, secure EDI pipeline). Options: SFTP flat file, API push (TLS), Secure EDI (837/835), Other (describe)
• Attach or describe the sample file schema and a representative sample file you will provide for onboarding (column-level definitions, sample rows).
• Define the acceptance criteria we will use to confirm the feed is integrated and complete (for example: record count match, field-level validation > 99%, test file pass).
• Verify any encrypted transport or certificate exchange requirements (SFTP key exchange, TLS ciphers, client certificate), and provide certificate owner contact.
• Present the named owner on your side for feed delivery and escalation and the expected file cadence at go-live.

Deploy Provider Prior Authorization Portal

• Cite which prior authorization criteria repository the portal should reference (your clinical criteria documents, national criteria, or custom rule set). Options: Your clinical criteria documents, National criteria repository, Custom rule set, Mixed / hybrid
• Describe required provider authentication and identity proofing methods for portal access (NPI-based SSO, SAML, OAuth). Options: NPI-based SSO, SAML, OAuth, Other (describe)
• Enumerate the functional test cases we must execute during portal UAT (submit PA, receive 277CA response, attach supporting docs, audit log verification).
• Confirm whether the portal must send real-time PA status callbacks into an EHR/EMR via HL7 2.x or FHIR messages. Options: HL7 2.x, FHIR, Both, None
• Name the owner who will coordinate provider onboarding and training and state the number of providers to provision at go-live.

Operate Prior Authorization Adjudication and Appeals

• How should prior authorization clinical criteria be versioned and published (criteria ID, effective date, change log)? Options: Criteria ID + effective date, Change log with version number, Documented P&T approval record, Other (describe)
• Name the clinical reviewer roles required for PA adjudications and the required credentials (PharmD, RPh, MD specialty). Options: PharmD, RPh, MD (specialty), Nurse practitioner, Other (describe)
• Are SLA targets required for PA turnaround by complexity tier (example: standard 24 hours, urgent 2 hours)? Options: Yes, No
• Detail the documentation fields you expect captured for each adjudication record (decision code, clinical rationale, reviewer ID, supporting documents).
• Include the integration points where PA status messages must be posted back to your provider portals or care management systems (API endpoint, SFTP drop, HL7 feed). Options: API endpoint, SFTP drop, HL7 feed, None

Operate Specialty Pharmacy Dispensing and Fulfillment

• Select which fulfillment channels must be supported for specialty products (ship-to-member home, buy-and-bill provider drop-ship, clinic-administered). Options: Ship-to-member home, Buy-and-bill provider drop-ship, Clinic-administered, Retail specialty pickup
• What temperature-control and cold-chain requirements apply for your specialty products and do you require chain-of-custody documentation or certificate of analysis (COA)? Options: Ambient, Refrigerated (2-8°C), Frozen, Cold-chain with COA
• Present the accountable pharmacist/licensed entity for dispensing and list required state licenses or DEA numbers we must validate.
• Choose the level of clinical support required for fulfillment coordination (24/7 nurse support, business-hours nurse, pharmacist counseling). Options: 24/7 nurse support, Business hours nurse, Pharmacist counseling only, On-call with SLA
• Estimate target fulfillment timelines by product class (for example: same-day, 1-2 business days) and describe backorder handling rules.

Operate Specialty Pharmacy Clinical Case Management

• Outline required care pathways and case management touchpoints (initial assessment, adherence calls cadence, side-effect monitoring intervals).
• State who should receive case management outcome reports and the desired cadence (monthly, quarterly, ad hoc). Options: Pharmacy Director, Medical Director, Care Management Team, Other (describe)
• Approve whether case notes must be pushed to your care management system via FHIR resource or exported as scheduled CSV extracts. Options: FHIR push, Scheduled CSV export, Both, None
• Recommend KPIs for clinical case management you want tracked (medication adherence %, reduction in hospitalizations, ER visit reduction). Options: Medication adherence %, Hospitalization reduction, ER visit reduction, Clinical biomarker improvement, Other (describe)
• Include any patient consent and state-specific data-sharing requirements we must follow for outreach and remote monitoring under HIPAA.

Deploy Biosimilar Adoption and Transition Program

• Enumerate which biosimilar substitution policies must be encoded (automatic therapeutic interchange, prescriber notification, patient consent). Options: Automatic therapeutic interchange, Prescriber notification required, Patient consent required, Exception-only policy
• Report how you want biosimilar uptake measured (volume share by NDC, net cost per dose) and provide the uptake targets you expect.
• Cite who will approve substitution exceptions and what clinical justification documentation is required.
• Agree which provider and member communication templates you require for transitions and list approved channels (provider letter, secure portal, email/SMS). Options: Provider letter, Member mail, Secure portal message, Email/SMS
• Detail the tracking fields you require for transitioned patients (original biologic NDC, switch date, biosimilar NDC, reason for switch).

Deliver Drug Utilization and Cost Analytics

• Report which analytics outputs are required at go-live (net drug cost PMPM, utilization by therapeutic class, rebate pass-through reconciliation). Options: Net drug cost PMPM, Utilization by therapeutic class, Rebate pass-through reconciliation, Custom KPIs
• Estimate acceptable data latency for analytics dashboards (near real-time, daily, weekly). Options: Near real-time, Daily, Weekly, Monthly
• State who should receive analytics access and which role-based dashboards to provision (pharmacy director, finance, clinical leadership). Options: Pharmacy Director, Finance team, Clinical leadership, Operations
• Upload or indicate whether you require raw data extracts for your internal analytics team and in which formats (Parquet, CSV, SQL). Options: Parquet, CSV, SQL dump, Other (describe)
• Outline baseline measures and benchmarks we should compute for success tracking (for example: net cost PMPM baseline quarter, biosimilar share baseline).

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Order Form / Subscription Agreement
• Data Processing Agreement (DPA) / HIPAA Business Associate Addendum (BAA)
• Service Level Agreement (SLA)
• Change Order Agreement
• Implementation Readiness & Data Access Confirmation

• Go-live Health Check
• First Outcomes Measurement
• Acceptance Gate Decision
• Quarterly Success Review
• Annual Outcomes Review

• Implement the agreed corrective actions with named owners and target dates.
• Confirm that deployment components are live and processing feed transactions without fatal errors.
• Produce a prioritized list of operational blockers with named owners and resolution dates.
• Establish baseline adoption signals to compare against first measurement outputs.
• Distribute a go-live validation report summarizing integration status, data gaps, and immediate fixes.
• Assign and publish owners and target resolution dates for each open blocker.
• Confirm access to the shared issue channel for ongoing tracking and escalation.
• Present first-period outcome data
• Determine whether net drug cost per member per month and prior-authorization average turnaround time are moving toward Solution Scope targets.
• Document root causes for any metric variance and name corrective owners with dates.
• Confirm the acceptance gate schedule and prerequisites for the day-90 decision.
• Deliver a data packet with raw and transformed datasets used for the metric calculations.
• Trend review of net drug cost and PA turnaround
• Update the acceptance gate readiness checklist to reflect outstanding remediation items.
• Restate the numeric acceptance criteria from Solution Scope
• Produce a documented acceptance decision with named buyer signatory for accepted criteria.
• List remediation items for any failed criteria with owners and completion dates.
• Confirm the incumbent decommission plan or read-only retention and the status of legacy data migration.
• Publish the acceptance decision record with signatory details and circulate to stakeholders.
• Create and schedule remediation tasks for unmet criteria with clear owners and deadlines.
• Execute the incumbent wind-down steps or confirm archival completion and update access controls.
• Confirm whether net drug cost per member per month and prior-authorization average turnaround time remain within acceptable variance of Solution Scope targets.
• Close or reassign the top operational blockers and update their resolution timelines.
• Prioritize any enhancement requests that materially affect scoped outcomes and assign owners.
• Owners to resolve the top three operational issues and report status before the next quarterly review.
• Update the shared issue and enhancement channel with current priorities and owners.
• Schedule a focused detailed review if any metric drifts more than the agreed variance from Solution Scope targets.
• Annual performance versus Solution Scope targets
• Document whether the program achieved the annual net drug cost savings and biosimilar uptake targets recorded in Solution Scope.
• Capture a set of documented lessons learned and incorporate them into the operational runbook.
• Assign long-term owners for any persistent issues and confirm the reporting and escalation cadence for the year ahead.
• Publish the annual outcomes report with data, variance analysis, and documented lessons learned.
• Update the operational runbook and reporting templates with agreed changes.
• Assign owners and deadlines for any persistent remediation items not yet closed.
• Reconfirm success criteria and owners
• Compare results to Solution Scope targets
• Deployment and data migration validation
• Lessons learned and process improvements
• Biosimilar uptake and specialty utilization update
• Present outcome data against each criterion
• Root cause diagnosis for gaps
• Open issues and blocker burn-down
• Early adoption signals and usage patterns
• Persistent issues and long-term ownership
• Document pass or fail per criterion and capture signatory
• Agree corrective actions and owners
• Remediation plan for failed or conditional items
• Operational runbook and reporting cadence confirmation
• Blockers and incident triage
• Enhancement requests and prioritization
• Agree immediate remediation actions
• Close outstanding remediation items from the acceptance gate
• Confirm timeline to acceptance gate
• Incumbent wind-down and data disposition
• Agree actions and next check-ins