Starting point: your current specialty scope and how you measure it

• How many specialty patients does your team manage in an average month? Options: 0-50, 51-200, 201-500, 501-1,000, More than 1,000
• In the last 12 months, which therapeutic areas made up most of your specialty spend? Options: Oncology, Autoimmune/IMID, Multiple sclerosis, HIV/hepatitis, Rare genetic disorders, Other
• Tell me about the top three specialty drugs you manage by spend or patient volume and what makes each operationally heavy
• When a new specialty prescription arrives, describe the typical sequence from receipt to first dispense in your organization
• To what extent do you currently track prior authorization approval speed as a KPI? Options: We track it daily with targets, We track it monthly without formal targets, We have anecdotal awareness only, We do not track it
• Who on your team owns escalation when a specialty case stalls, and how quickly do they typically act? Options: Dedicated case manager (same day), Clinical pharmacist (1-3 days), Operations lead (3-7 days), No single owner

Where therapy starts stall and who ultimately pays the cost

• If one point in your specialty workflow could be fixed tomorrow, which delay should it be to free the most patients to start therapy?
• How often does a benefits or prior authorization issue push the first dose beyond your target window? Options: Nearly every case, Often (25-50%), Occasionally (10-25%), Rarely (<10%)
• Describe a recent patient who abandoned therapy because of cost, prior authorization, or logistics and the downstream impact on care or costs
• Point to the step that causes the most rework for clinicians or case managers, claims denials, PA resubmissions, documentation requests, or benefit investigations Options: Initial benefits check, PA submission, Clinical documentation collection, Appeals, Financial assistance enrollment
• How long is the typical window from prescription to patient first dose today, including PA and logistics delays? Options: 0-3 days, 4-7 days, 8-14 days, More than 14 days
• What single operational failure would make you pause onboarding a new specialty partner today?

Who touches each case and where handoffs break down

• When a case deviates from timeline, which role is alerted first and does that alert usually change the outcome? Options: Prescriber/clinic, Internal case manager, Pharmacist, Payer case manager, Manufacturer support
• List the external stakeholders who routinely require updates on active specialty cases Options: Payer case managers, Manufacturer patient support, Clinic specialty nurse, Care management vendor, None regularly required
• Describe how responsibilities split between prescribers, your pharmacy operations, payer case managers, and manufacturer support for PA, enrollment, and follow-up
• Point to the communication channel that most often fails to carry the full clinical record, phone, EHR message, portal, or payer portal Options: Phone, Fax, EHR message, Manufacturer portal, Payer portal, Secure email
• If your clinician teams could no longer reliably contact an external stakeholder critical to PA approvals, would that stop new patient starts? Options: Yes, immediately, It would slow starts significantly, No, we have workarounds

The prior authorization squeeze: root causes and appeals

• Walk me through the last prior authorization that exceeded your target approval time, what specifically caused the delay, and how you tried to recover
• How many PA submissions are returned for missing clinical documentation in a typical month? Options: 0-10, 11-50, 51-200, More than 200
• Name the payer edits or clinical criteria that most commonly trigger denials or lengthy reviews Options: Diagnosis mismatch, Missing supporting labs, Step therapy / prior therapy requirements, Formulary exclusions, Quantity limits
• Outline the appeals workflow and average time from denial to overturn for your most frequent denial types
• What turnaround time on PA approvals would make you move a material share of volume to a new partner immediately? Options: <24 hours, 1-3 days, 4-7 days, More than 7 days

Competitive landscape and the other options on your table

• List the vendors, incumbent partners, or internal projects you are actively evaluating as alternatives to an external specialty pharmacy partner Options: Incumbent specialty pharmacy, New external vendors, Internal build within health system, Manufacturer-managed pathway, Other
• For each alternative you named, what is the one claim they make that matters most to your procurement or clinical team? Options: Faster PA approvals, Higher adherence, Lower total cost of care, Better manufacturer access, Superior reporting
• What conditions would have to hold true for you to remain with your current incumbent rather than moving to a new partner?
• Has anyone on your team proposed solving this internally, and if so, what resource gap prevents that plan from being viable? Options: Yes, staffing gap, Yes, technical integration gap, Yes, budget gap, No one has proposed it
• Would a partner that matched your top KPI improvements but could not participate in limited distribution networks or meet manufacturer requirements be acceptable to your team? Options: No, limited distribution participation is mandatory, Maybe, with compensating benefits, Yes, if other KPIs are exceptional

Operational readiness and the hard gates we must clear

• Identify the single integration or infrastructure gap that would stop the project before deployment
• Which core systems must the seller connect to for the project to proceed, select all that apply Options: EHR/Clinical system, Claims adjudication system, Patient registry, Manufacturer portals, Customer portal/CRM, Logistics/fulfillment system
• Who owns the EHR integration, claims data feeds, and API access on your side, and can that owner commit to development time in the next quarter? Options: Internal IT team, Third-party integrator, Vendor-managed, No clear owner yet
• How mature are your patient consent records for third-party access and where are the main gaps Options: Consents in place and auditable, Partial consent coverage, Consents not consistently collected, We need to build consent process
• Name any operational limits you have for cold chain handling, daily shipment windows, and rural delivery coverage that would impact go-live
• Would inability to grant secure read access to claims and EHR data within 30 days prevent a pilot from proceeding? Options: Yes, it blocks the pilot, No, we can run a limited pilot, Depends on which data sources are missing

Success signals, pilot scope, and the near-term decision

• Assuming a 90-day pilot meets your PA speed and adherence targets, which internal approvals would still be required to expand Options: Clinical leadership sign-off, Medical director approval, Procurement/contract signature, Finance budget release, All of the above
• Provide the numeric targets you would set for PA approval time in days, adherence at 6 months, and financial assistance enrollment rate
• How would you like performance reported during the pilot, frequency and channel — daily dashboard, weekly summary, clinician alerts, or monthly executive review? Options: Daily dashboard, Weekly operational summary, Clinician-level alerts, Monthly executive review, Combination
• What would you consider a deal-killer in the pilot outcomes or reporting that would stop a full roll-out?
• Propose a follow-up timing to review pilot criteria and decision gates, immediately after scoping, before build, or after a technical readiness check Options: Immediately after scoping, Before build starts, After technical readiness check, Other
• Provide the titles of the stakeholders who must sign the final SOW and contract for the pilot to move into paid deployment

• Solution Experience: Faster Starts & Patient Success

• Confirm the current state and what it is costing you
• You confirm the demonstrated workflows eliminate the manual handoffs and delays described in Discovery.
• Provide two representative patient/payer scenarios including a sample prior-authorization form and benefit response to be used in the timed simulation
• Run a timed prior-authorization and enrollment simulation on the provided scenarios and deliver a timeline comparison and root-cause notes before the follow-up session
• Walk an end-to-end complex payer scenario
• You agree that the shown PA approval and financial assistance timelines meet the threshold needed to reduce patient abandonment.
• Walk a high out-of-pocket patient scenario with financial assistance
• You accept the proposed pilot scope and KPI targets to prove outcomes in your environment.
• Draft a one-page pilot scope with KPI targets for PA approval time, adherence, and financial assistance enrollment for mutual review
• Show the real-time status reporting and KPI tracking
• Confirm the operational future state
• Agree next evidence and pilot measures

• Solution Experience: Faster Starts & Patient Success
• Solution Experience Deck
• Solution Brief — Specialty Pharmacy Service

• meeting
• slides
• document

• Prior Authorization Submission and Appeals Management
• Benefits Investigation and Coverage Verification
• Patient Financial Assistance Enrollment and Fund Access
• Specialty Medication Dispensing and Temperature-Controlled Delivery
• Cold Chain Storage and Real-Time Shipment Tracking
• Limited Distribution Medication Network Fulfillment
• Clinical Pharmacist Medication Counseling Sessions
• Proactive Adherence Monitoring and Outreach
• Side-Effect Management and Clinical Triage
• Refill Coordination and Refill Synchronization
• Therapeutic Drug Monitoring and Lab Coordination
• Real-Time Patient Status Portal Access and Prescriber Updates
• Outcomes Reporting and Adherence Analytics

Prior Authorization Submission and Appeals Management

• Which prior authorization (PA) workflows do you use today (electronic PA portal, fax, phone, EHR-based PA), and which should we support first? Options: Electronic PA portal (payer web), Fax-based PA, Phone-assisted PA, EHR-embedded PA workbench, Other
• How many unique PA forms or templates (by therapy area or payer) must be supported at go-live (list by form name or payer ID)?
• Who on your team currently tracks PA decision status and will be the day-to-day contact for escalations (name and role)?
• Provide the acceptance threshold for PA turnaround time that will validate the service (e.g., percentage of approvals within X business days and sample payer IDs to measure). Options: Approve 70% within 3 business days, Approve 85% within 5 business days, Custom (describe below)
• Specify the documents we must attach to initial PA submissions (clinical notes, labs, prior therapies, chart extracts) and the preferred file formats. Options: Clinical notes (PDF), Lab reports (PDF/structured), Medication history (CSV/HL7), Other
• Identify any payers for which you require an appeals playbook or prior-authority-specific logic (list payer IDs or plan names and appeal levels).

Benefits Investigation and Coverage Verification

• Which eligibility transactions or checks do you need supported at intake (EDI 270/271, payer portal lookup, benefit inquiry API)? Options: EDI 270/271, Payer web portal look-up, Benefit inquiry API (FHIR/REST), Manual member card review
• How many payer benefit rules must be encoded (e.g., step therapy, quantity limits, diagnosis restrictions) and provide examples by payer BIN/PCN if available.
• Who on your prior authorization or pharmacy benefits team will approve exceptions to coverage assumptions during the pilot?
• Specify the member identifiers and data elements we must capture for verification (e.g., member ID, BIN, PCN, group number, RxBIN group).
• List common adverse coverage outcomes we should detect at benefits check (non-covered, step-therapy required, prior authorization required, specialty carve-out) and indicate which require immediate outreach. Options: Non-covered, Step therapy required, Prior authorization required, Specialty carve-out, Other
• Describe any payer-specific eligibility rules that currently cause therapy delays for your members (include payer ID and a short example).

Patient Financial Assistance Enrollment and Fund Access

• Which types of financial assistance must we enroll patients in (manufacturer patient assistance programs, copay cards, foundation grants), and which program IDs or manufacturer program names should be prioritized? Options: Manufacturer patient assistance (PAP), Copay assistance/coupon, Independent foundations/grants, Bridge programs
• How many patients per month do you expect will require financial assistance enrollment at launch (estimate volume)? Options: Less than 10, 10-50, 51-200, 200+
• Provide the consent and documentation artifacts required for enrollment (signed PAP application, proof of income, insurance denial letters) and accepted file formats.
• Which payer or plan edits (e.g., coordination of benefits rules, Medicare Part D exceptions) must the financial assistance workflow consider before fund disbursement?
• Indicate whether you require direct-to-patient fund disbursements or pharmacy-applied assistance and name the preferred disbursement method. Options: Pharmacy-applied assistance (at fill), Direct-to-patient disbursement, Hybrid / program dependent
• Describe evidence you will accept to confirm enrollment success and access to funds (e.g., grant award letter, copay card activation ID). Options: Grant award letter, Copay card activation/ID, Confirmation from manufacturer hub, Other

Specialty Medication Dispensing and Temperature-Controlled Delivery

• Which dispensing models do you require (ship-to-patient, ship-to-clinic, clinic-administered pickup) for specific therapy types or sites of care? Options: Ship-to-patient, Ship-to-clinic/provider, Clinic-administered pickup, Home infusion coordination
• How should high-cost, limited-quantity fills be handled (partial fills, split shipments, prior notice to prescriber)? Options: Partial fills allowed, Full fill only, Split shipments with prescriber notice
• Provide the dispensing data elements that must flow to your EHR or care management system at dispense (NDC/HRI, lot number, expiry date, Rx number, prescriber NPI).
• Specify any controlled-substance scheduling or REMS (Risk Evaluation and Mitigation Strategy) requirements we must enforce at dispensing for particular drugs (list drug codes or REMS names).
• Describe preferred delivery time windows and verification steps for patient receipt (signature required, photo proof, ID check). Options: Signature required, Photo proof of delivery, No signature required, ID check on delivery
• Identify any accreditation or dispensing audit artifacts you will require for compliance review (audit logs, temperature logs, chain-of-custody manifests).

Cold Chain Storage and Real-Time Shipment Tracking

• Which temperature ranges must be supported by your therapies (e.g., 2-8°C, -20°C, ambient), and for which NDCs or product codes?
• Which shipment telemetry and alerting do you require (continuous temperature log with alerts, dose-level sensors, GPS geofencing)? Options: Continuous temperature telemetry, Dose-level temperature sensor, GPS location tracking, Geofencing alerts
• How many distribution nodes (warehouses or hubs) will receive refrigerated inbound stock at launch and what are their receiving windows?
• Describe the chain-of-custody documents you will require on receipt at clinic or patient delivery (temperature certificate, manifest, shipment ID).
• Provide the acceptance criteria we should use to confirm cold-chain integrity on arrival (for example: 95% of shipments with no excursions and telemetry available for review). Options: 95% shipments no excursions, 99% shipments no excursions, Custom acceptance (describe)
• List the logistics carriers or carrier categories you prefer for temperature-controlled last-mile and whether white-glove handling is required. Options: Specialty medical couriers, Standard carriers with temperature service, White-glove courier required, No preference

Limited Distribution Medication Network Fulfillment

• Which limited distribution networks (LDNs) or manufacturer channel lists must we be admitted to before fulfillment (provide the manufacturer program IDs or LDN list IDs)?
• How many distinct limited-distribution SKUs do you expect to route through the network at launch (list NDCs or product codes)?
• Which manufacturer-required documentation or onboarding artifacts are needed for LDN participation (payer attestation, pharmacist credentials, site accreditation evidence)?
• Identify the exception processes when an LDN partner cannot supply a product (backorder notification window, alternative sourcing approvals).
• Provide the acceptance evidence that will confirm LDN fulfillment readiness (for example: certification of enrollment or manufacturer confirmation number). Options: Manufacturer confirmation number, Certification of enrollment document, Letter of participation, Other
• Describe any reporting or reconciliation cadence the manufacturer requires for LDN drugs (daily dispenses, monthly inventory reports). Options: Daily dispense reporting, Weekly reconciliation, Monthly inventory report, Other

Clinical Pharmacist Medication Counseling Sessions

• Which therapy areas require scheduled pharmacist counseling at start-of-therapy (oncology, autoimmune, transplant, rare disease), and what is the expected cadence? Options: On therapy start, Weekly for first month, Monthly thereafter, Ad-hoc/triggered
• Who are the authorized clinical staff that will conduct counseling and what credentials or documentation do you require (pharmacist license, certification)?
• Provide the counseling content that must be documented in the patient record (dose administration training checklist, adverse event counseling note, storage instructions).
• Specify whether counseling sessions should be offered in-person, by telehealth, or by phone and any platform requirements (EHR telehealth link, recorded consent). Options: In-person, Telehealth/video, Phone call, Multi-channel
• Describe the measurable targets for counseling effectiveness you expect tracked (patient comprehension score, return demonstration pass rate, documented action plan).
• List any language or accessibility needs we must plan for during counseling (interpreters, large-print materials, ASL).

Proactive Adherence Monitoring and Outreach

• Which adherence thresholds should trigger outreach (days past expected fill date, missed dose count) and specify thresholds (for example: outreach after 3 missed doses).
• How would you like outreach prioritized across channels (call center first, then SMS, then email) and are there restrictions (no SMS for Medicare Part D members)?
• Provide the patient populations or therapy cohorts that should receive automated adherence reminders versus pharmacist-led outreach. Options: All specialty patients, High-risk cohorts only, Therapy-specific cohorts, Custom list
• Identify the adherence metrics you require in reports (proportion of days covered PDC, medication possession ratio MPR, refill gap days) and target thresholds. Options: PDC, MPR, Refill gap days, Other
• Describe any integrations needed to detect adherence events (pharmacy dispense feed, claims adjudication feed, EHR medication list) and provide endpoint details if available.
• Specify consent or communication preference documentation we must capture before outreach (SMS consent, preferred language, best contact times).

Side-Effect Management and Clinical Triage

• Which adverse event severity scale or triage protocol should we apply (mild/moderate/severe with recommended escalation paths) and attach an example protocol if available.
• Who are the escalation contacts at your clinical team for urgent side-effect events (name, role, phone/email), and what are acceptable response SLAs?
• Provide the list of common therapy-specific side effects that require proactive monitoring and the monitoring cadence (daily, weekly, monthly).
• Indicate whether you require structured symptom intake forms for teletriage and which data elements they must capture (vital signs, lab values, symptom onset date). Options: Structured intake form required, Free-text triage note only, Both
• Describe the documentation artifacts that validate clinical triage completion for audit (triage note, callback log, escalation ticket ID).
• List any payer or formulary constraints that change triage or treatment recommendations (e.g., step edits require prior authorization before symptomatic management).

Refill Coordination and Refill Synchronization

• Which refill authorization authority do you require (prescriber EHR e-sign, fax, delegated refill protocol) and for which therapies? Options: Prescriber e-sign in EHR, Fax renewal, Delegated refill protocol, Patient-initiated refill
• How many patient refills per month do you expect to process and what is the target turnaround time for refill approvals? Options: Less than 50, 50-200, 200-500, 500+
• Provide the synchronization rules you want enforced when patients are on multiple specialty therapies (align refill dates, split fills, auto-stagger).
• Identify the refill-denial reasons that should trigger automatic prescriber outreach (coverage denial, lab monitoring overdue, therapy hold). Options: Coverage denial, Lab overdue, Therapy hold, Other
• Specify the data elements required in refill confirmation notifications to prescribers and patients (next fill date, quantity, lot/expiry if applicable).
• Describe any refill adherence programs you want enabled (auto-refill opt-in, adherence packaging, synchronized ship dates). Options: Auto-refill, Synchronized ship dates, Adherence packaging, None

• Master Services Agreement (MSA)
• Statement of Work (SOW)
• Service Level Agreement (SLA)
• Pricing & Order Form
• Data Processing Agreement / Business Associate Addendum (DPA/BAA)
• Limited Distribution Network Participation Addendum
• Patient Data Sharing & Consent Authorization
• KPI & Reporting Annex

• Go-live Health Check (Week 1-4)
• First Outcomes Measurement (Weeks 4-10)
• Acceptance Gate Review (Day ~90)
• Ongoing Quarterly Success Review

• Deliver the monthly KPI summary dashboard aligned to Service Scope targets for stakeholder review.
• Deliver the dataset and dashboard views that will be used at the Acceptance Gate Review.
• Restate acceptance criteria and numeric targets
• Produce a documented acceptance decision against each numeric target recorded in Service Scope, including buyer signatory capture where applicable.
• If any criteria are conditional or failed, agree remediation actions, deadlines, and the verification method.
• Confirm the transition plan from onboarding to the ongoing success cadence.
• Publish the acceptance decision record that cites Service Scope targets and the measured outcomes.
• Create and publish remediation task list for any conditional or failed criteria with resolution dates and verification steps.
• Schedule the first Ongoing Quarterly Success Review and share the recurring reporting package.
• Re-confirm success criteria and owners
• KPI trend review vs Service Scope targets
• Confirm KPI trajectories for prior authorization approval time and six-month adherence rate and financial assistance enrollment rate remain acceptable against Service Scope targets.
• Resolve or reprioritize the shared issue channel items and define the quarter's top operational improvements.
• Agree the monitoring cadence and deliverables for the next quarterly review.
• Maintain the shared issue channel with weekly triage notes and publish the quarterly prioritized backlog.
• Execute agreed operational adjustments and report impact in the next quarterly review.
• Confirm all critical deployment components (dispensing, integrations, patient consent, cold-chain) are operational or have a remediation plan with target dates.
• Produce a prioritized list of open issues with owners and due dates for immediate remediation.
• Agree the timeline and criteria for progressing to the First Outcomes Measurement meeting.
• Publish the deployment validation checklist and current issue tracker with owners and target resolution dates.
• Update patient consent and delivery records to confirm readiness for active case handling.
• Execute agreed immediate remediation tasks and report status in 7 calendar days.
• Present first KPI data vs targets
• Determine whether median prior authorization approval time and patient adherence rate and financial assistance enrollment rate are trending to meet Service Scope targets.
• Identify top 3 root causes for any KPI shortfalls and agree concrete corrective actions with target dates.
• Confirm the timeline and data requirements for the Acceptance Gate Review.
• Produce a root-cause report with case-level evidence for each KPI gap and circulate to stakeholders.
• Implement agreed corrective actions (for example, PA workflow fixes, targeted patient outreach, financial assistance enrollment drives) and track progress weekly.
• Present outcome data against each criterion
• Open issues and enhancement requests
• Deployment and integration validation
• Diagnose root causes for gaps
• Document pass, conditional pass, or fail per criterion
• Early adoption and usage signals
• Operational performance highlights
• Operational and clinical exception review
• Open issues and blockers
• Formal acceptance decision and record
• Agree corrective actions and timeline
• Agree quarterly action plan
• Agree immediate remediation actions
• Close or reprioritize backlog items
• Agree remediation plan for any failed or conditional items