Start Here: What's on Your Mind About Drug Spend?

• What's the single biggest objective you need a PBM relationship to deliver in the next 12 months? Options: Reduce net pharmacy trend, Increase rebate pass-through transparency, Improve specialty drug management, Protect or expand network access, Reduce member friction with prior auth, Meet state Medicaid mandates/compliance, Other
• How would you describe your current confidence that your pharmacy vendor is delivering measurable, auditable savings? Options: Very confident, Somewhat confident, Neutral/Unsure, Skeptical, Actively concerned
• Which of the following outcomes matters most to your CFO right now? Options: Lower net spend (after rebates), Predictable trend and budget certainty, Improved outcomes for high-cost members, Lower per-member administrative cost, Regulatory/compliance certainty, Other
• Who on your team will feel positive impact first when the PBM is performing well? Tell us their role and why.
• If you had one quick win you could point to for the next quarter, what would it be?

If This Keeps Going, What Will Break?

• What part of your drug benefit are you most worried is quietly out of control? Options: Specialty spend, Net trend after rebates, Formulary exceptions/medical benefit shifts, Rebate retention or reconciliation, Pharmacy access gaps (rural/narrow networks), Member experience/prior auth backlog, Other
• How often do you see unexpected formulary disruption or therapeutic access issues when changing or optimizing PBMs? Options: Every transition, Often, Sometimes, Rarely, Never
• Give a recent example of a pharmacy-related problem that had outsized impact on your plan (cost, member complaints, or compliance). What happened and who raised the alarm?
• How long has this pain been active and what attempts have you made to fix it? Options: Less than 6 months, 6–12 months, 1–3 years, 3+ years
• When those issues surface, what are the usual emotional and political consequences inside your organization?

Where Are the Hidden Dollars (and Anger)?

• How confident are you that rebates reported to you reflect the full manufacturer payments tied to your members? Options: Completely confident, Mostly confident, Somewhat confident, Doubtful, We don't know
• Which pricing model does your incumbent PBM use today? Options: Pass-through with administrative fee, Pass-through with percentage admin, Spread pricing, Hybrid (mix of spread & pass-through), Manufacturer-specific carve-outs, Unsure/varies by contract
• Where do you suspect value is being withheld (e.g., spread on network claims, retained rebates, opaque GDUFA fees)?
• What specific reporting or auditability do you currently lack that would make rebate and net spend feel transparent to you?
• If we proposed a performance guarantee tied to net trend and rebate pass‑through, which of these would be most important to you? Options: Cash-back guarantees, Trend cap with shared savings, Rebate reconciliation & audit rights, Clinical outcome guarantees, Network access minimums, Other

Who Holds the Keys—and Who Gets Blamed?

• Who are the decision-makers and influencers for your PBM strategy, and what does success look like to each of them?
• Which stakeholder tends to be the most conservative about change—and what do they worry will go wrong? Options: CFO/Finance, HR/Benefits Director, Clinical Leadership, Procurement, Board/Policy Makers, Other
• How do your benefits consultant and broker weigh into contracting, and have they pushed for pass-through or guarantees before? Options: They prioritize pass-through, They prefer hybrid models, They prioritize operational stability, They vary by client, No strong position
• Who owns pharmacy clinical strategy vs. network contracting vs. rebate reconciliation in your org today?
• When problems happen, who is typically asked to explain them to leadership or regulators, and how does that affect decision-making?

Imagine a PBM That Actually Demonstrates Value

• If a PBM could prove it reduced your net drug trend by 3–5% without narrowing access, how would that change your priorities? Options: Shift budget to clinical programs, Reduce premiums or contributions, Invest in member services, Reallocate to other benefits, Other
• What clinical or patient outcomes would you want to see tied to financial guarantees (e.g., reduced hospitalizations, improved adherence for high-cost meds)?
• Describe the ideal level of transparency you’d expect in rebate reporting and reconciliation—what would make you sleep better at night?
• What would a successful PBM transition look, sound, and feel like to your members and staff at 30, 90, and 365 days post go‑live?
• What would be an unacceptable outcome even if financial targets were met? Options: Significant member access loss, Major adjudication errors, Increased clinical adverse events, Regulatory non-compliance, Other

Data, Feeds, and the Paper Trail

• If you had to pick one data pain that would derail any optimization project, what is it? Options: Missing/misaligned claims files, Delayed rebate remittance detail, Inaccurate formulary mapping, No member-level clinical data, Poor provider/NPI mapping, Other
• Which data feeds do you currently receive from your PBM and at what cadence? Options: Eligibility (daily), Claims paid (daily), Claims paid (weekly), Rebate remittance (monthly), Clinical events (ad-hoc), We receive minimal feeds, Other
• How accessible are line‑level rebate allocations and manufacturer invoices for your finance/audit team? Options: Fully accessible and auditable, Available but with delays, Partial access with redactions, Unavailable
• When you look at your claims and network files, where do you see the biggest mapping or adjudication mismatches? Please give examples.
• What technical connectors or SFTP/API capabilities must a vendor support to be viable for you? Options: SFTP, REST API, HL7, EDI 834/835/837, Direct DB access, Other

Switch, Small Change, or Stay Put?

• How willing are you to accept short-term disruption if it produces clear long-term net savings? Options: Very willing, Somewhat willing, Depends on protections, Not willing
• What’s your realistic timeline for making a vendor change or for negotiating a materially different commercial model? Options: Immediate (0–3 months), Near-term (3–6 months), Mid-term (6–12 months), Longer (12+ months), Undecided
• What transition risks keep you up at night (e.g., claim disruption, patient interruption, financial reconciliation), and which of these would you require contractual protections for? Options: Claims adjudication continuity, Formulary continuity for ongoing therapies, Rebate reconciliation guarantees, Network access preservation, Member communications handling, Other
• Have you ever attempted to bring rebate pass‑through or guaranteed trend commitments into a contract before? What was the result and what stopped it from working?
• What minimum assurances (data access, parallel testing, financial waterfall transparency) would you need before agreeing to a go‑live date?

Commitment, Measurement, and What Success Will Look Like

• If we asked you to define three non-negotiable acceptance criteria for go‑live, what would they be?
• Which KPIs will you use to evaluate success in year one? Pick up to five. Options: Net pharmacy trend, Rebate pass-through percentage, Specialty spend per patient, Prior authorization turnaround time, Generic dispensing rate, Member satisfaction/NPS, Pharmacy network access score, Clinical outcomes (adherence, hospital days)
• How frequently would you want performance reviews, and who should attend them? Options: Weekly during transition, Bi-weekly first 90 days, Monthly thereafter, Quarterly strategic review, Ad-hoc for incidents
• What governance structure would help you feel protected—single-point contract owner, steering committee, or external audit rights? Options: Single contract owner, Cross-functional steering committee, Independent audit rights, Escalation matrix with SLA penalties, Other
• Finally, what would success feel like to your members and to your CFO one year after implementation?

• Modeling Kickoff & Current State Validation
• Financial Impact Modeling Workshop
• Clinical Outcomes & Utilization Modeling
• Rebate Flow, Contracting & Reconciliation Workshop
• Solution Experience Validation & Executive Decision

• Identify contract clauses that must be included to enforce the modeled pass-through and guarantees.
• Seller to update model assumptions where customer-provided corrections are validated.
• Schedule a follow-up session to reconcile any material variances (>5% PMPM) found by the customer.
• Confirm Clinical Objectives & Guardrails
• Agree on projected utilization and clinical KPI changes attributable to each intervention.
• Confirm how clinical changes are translated into financial impact and any offset assumptions.
• Define clinical acceptance criteria and guardrails to minimize member/provider disruption.
• Identify additional clinical data or stratifications needed for refined modeling.
• Customer to provide clinical stratification files (e.g., diagnosis links, specialty patient lists) if not already supplied.
• Seller to produce a clinical impact memo tying utilization changes to financial offsets and expected KPIs.
• Both parties to agree on monitoring cadence and dashboards to track clinical KPIs post-implementation.
• Review Current Rebate Waterfall
• Produce a validated rebate projection that maps to contract and reconciliation mechanics.
• Agree on reporting fields, audit cadence, and evidence required to support modeled rebate outcomes.
• Introductions & Objective Alignment
• Confirm the escalation and dispute process for any reconciliation variances.
• Customer to provide detailed rebate remittance files and any manufacturer reconciliation histories.
• Seller to draft sample contract language and reconciliation SLAs tied to modeled outcomes.
• Both parties to define a test reconciliation run to validate reporting fields and timing.
• One-Sentence Diagnosis, Consequence & Future-State Recap
• Obtain explicit executive confirmation that the modeled future state addresses the diagnosed problem.
• Secure decision to advance the validated strategy into Solution Scope or document required conditions for approval.
• List remaining risks and assign owners with timelines for resolution prior to contracting.
• Agree on delivery of final model pack and executive summary for procurement/legal review.
• Customer to provide executive sign-off or a prioritized list of conditions for sign-off within agreed SLA.
• Seller to deliver final model pack, executive summary, and recommended contract clauses to procurement counsel.
• Schedule Solution Scope workshop to translate the validated model into defined modules, deliverables, and acceptance criteria.
• Agree on one concise current-state statement that drives the modeling scope.
• Surface and quantify the key consequences that make change urgent.
• Confirm required data files, owners, and delivery dates for modeling.
• Align on a single-sentence future-state outcome the model must prove.
• Establish stakeholder roles and approval cadence for successive workshops.
• Customer to deliver anonymized claims extract (12–24 months) with defined fields by agreed date.
• Customer to provide current formulary files, rebate remittance details, and NDC-to-drug-class mapping.
• Assign data owners and confirmation contacts for each dataset.
• Seller to circulate the agreed one-sentence current-state, consequence, and future-state statements as a baseline for modeling.
• Recap Current State, Consequence & Future State
• Deliver a validated baseline financial model that matches the customer's view of current spend.
• Produce scenario outputs showing projected net cost, trend, and rebate realization for proposed strategies.
• Identify and quantify the top 3 drivers of projected savings and the assumptions that most affect outcomes.
• Obtain explicit customer confirmation on model assumptions or capture required changes.
• Agree timeline for final model deliverable and executive summary.
• Seller to deliver the model workbook with scenario tabs, driver decomposition, and sensitivity runs within agreed SLA.
• Customer to review model outputs and provide written confirmation or exception list within 5 business days.
• Proposed Pass-Through & Contract Scenarios
• Proof: Key Financial & Clinical Outcomes
• Modeling Methodology & Assumptions
• One-Sentence Current State
• Current Utilization and Clinical Risk Profile
• Intervention Mapping
• Explicit Consequence Review
• Validation: Customer Confirmation
• Baseline (Status Quo) Model Run
• Reconciliation Mechanics & Timing
• Risks, Open Issues & Mitigations
• Modeled Clinical Outcomes & Cost Tie-In
• Future State Hypothesis
• Reporting, Auditability & Controls
• Proposed Strategy Scenarios
• Contractual Clauses to Support the Model

• Design and Maintain Client Formularies
• Apply Real-Time Formulary Edits at POS
• Configure and Enforce Prior Authorization Rules
• Deploy Step Therapy and Clinical Edit Protocols
• Negotiate Manufacturer Rebate Agreements and Contracts
• Pass-Through Rebate Remittance and Reconciliation
• Administer Retail Pharmacy Network Contracts
• Operate Mail-Order Pharmacy Fulfillment
• Operate Specialty Pharmacy Dispensing and Management
• Run Specialty Patient Case Management Hub
• Adjudicate Pharmacy Claims and Process Payments
• Deliver Monthly Pharmacy Trend and Rebate Reports
• Administer Contractual Performance Guarantees and Credits
• Provide Real-Time Member Price Transparency Tools

Design and Maintain Client Formularies

• Do you require a full initial formulary design, ongoing maintenance, or both? Options: Initial design, Ongoing maintenance, Both
• What formulary tier structure do you want us to support? Options: 3-tier (Generic/Preferred/Non-preferred), 4-tier (incl. Specialty or Brand carve), 5-tier (multiple specialty tiers), Custom
• Which therapeutic classes or specific drugs must be included, excluded, or restricted (list or attach)?
• How frequently do you expect formulary changes (updates, removals, exceptions)? Options: Monthly, Quarterly, Semi-annually, Annually, Ad-hoc as needed
• Do you require clinical review committees or client approval gates for changes? Options: Yes - clinical committee, Yes - client approval required, No - PBM-managed
• Are there state Medicaid, ERISA, union, or other contract constraints we must adhere to?

Apply Real-Time Formulary Edits at POS

• Do you want edits enforced at point-of-sale, or flagged for pharmacist/provider review? Options: Enforce at POS, Flag for review, Combination by drug class
• Which edit types are required (e.g., tier override, step-through enforcement, prior-auth redirect)? Options: Tier override, Step therapy trigger, Prior authorization redirect, Quantity limits, Other
• What tolerance for override rates do you accept before requiring root-cause analysis? Options: <1%, 1-3%, 3-5%, >5%
• Do you need real-time messaging to members/pharmacies explaining edits at POS? Options: Yes - automated patient messaging, Yes - pharmacy messaging only, No
• Are there PBM switch or historical-mapping concerns for formulary codes that impact POS logic? Options: Yes - mapping required, No - clean mapping, Not sure
• Describe any specific retail POS systems or pharmacy chains requiring custom integration or testing (list):

Configure and Enforce Prior Authorization Rules

• Which drug classes or criteria should trigger prior authorization (PA)?
• Do you prefer manual PA determinations, rules-based automation, or hybrid workflows? Options: Manual reviewer, Automated rules engine, Hybrid (rules + manual exceptions)
• What target turnaround time do you require for PA decisions? Options: Same day, 24 hours, 48 hours, 72+ hours
• Should PA approvals be time-limited (e.g., 6 months) and require reauthorization? Options: Yes - specify duration, No - ongoing until change, Case-by-case
• Do you require electronic prior authorization (ePA) integrations with prescriber EHRs? Options: Yes - essential, Preferred but not required, No
• Are there specific clinical criteria or externally-sourced guidelines (e.g., NAS, specialty society) to embed into PA rules?

Deploy Step Therapy and Clinical Edit Protocols

• Which therapeutic areas should have step therapy protocols applied?
• Do you want hard-step enforcement (no fill until prior step tried) or soft-step (financial nudges/notifications)? Options: Hard enforcement, Soft nudges, Hybrid
• Should step-therapy exceptions be adjudicated via clinical review, or through tiered auto-exceptions? Options: Clinical review required, Automated exception rules, Combination
• What clinical or utilization data sources may be used to validate step adherence (claims history, EHR, PDMP)? Options: Claims history, EHR integration, PDMP, Patient-reported, Other
• Do you require retrospective monitoring of step therapy compliance and override reporting? Options: Yes - monthly reports, Yes - quarterly reports, No
• Are there member appeals or rapid resolution timelines to incorporate into the protocol? Options: Yes - defined SLAs, No, TBD

Negotiate Manufacturer Rebate Agreements and Contracts

• Do you require the PBM to negotiate rebates on your behalf or pass-through existing manufacturer contracts? Options: PBM negotiates on our behalf, Pass-through existing contracts, Combination
• Which rebate structures are acceptable (per-unit, aggregate quarterly, guaranteed minimums)? Options: Per-unit, Aggregate quarterly, Guaranteed minimums, Tiered performance-based
• Are you seeking transparency into manufacturer contract terms (e.g., actual contract rates, clawbacks)? Options: Full transparency (contract-level), High-level summary only, No
• Do you require performance guarantees tied to rebate realization for specific therapeutic classes? Options: Yes - specify classes, No, TBD
• What historical rebate performance or forecast accuracy benchmarks should be used in negotiations?
• Any anti-kickback/compliance or state-specific restrictions that affect rebate contracting? Options: Yes - describe, No, Unsure

Pass-Through Rebate Remittance and Reconciliation

• Do you require true pass-through remittance to the client or reconciliation with netting provisions? Options: Full pass-through remittance, Reconciliation with netting, Custom model
• How frequently do you want rebate remittance and reconciliation statements delivered? Options: Monthly, Quarterly, Semi-annually, Annually
• What level of detail do you need in reconciliation (drug-level, NDC-level, manufacturer-level)? Options: Drug-level, NDC-level, Manufacturer-level, Contract-level
• Do you require audit access to manufacturer contracts and PBM reconciliation methods? Options: Yes - full audit rights, Yes - limited audit rights, No
• Should remittance align to client fiscal periods or to manufacturer payment schedules? Options: Client fiscal periods, Manufacturer schedules, Hybrid
• Are there special allocation rules for rebates associated with carve-outs or carve-ins (e.g., specialty carve-out)? Options: Yes - describe, No, TBD

Administer Retail Pharmacy Network Contracts

• Do you require an open, preferred, or narrow retail pharmacy network? Options: Open network, Preferred network, Narrow network, Hybrid
• Which retail chains or independent pharmacies are mandatory to include or exclude?
• Do you need network access guarantees (distance, percentage of members within X miles)? Options: Yes - distance-based, Yes - percentage coverage, No
• Should dispensing fees and network discounts be contracted directly or indexed to benchmarks? Options: Direct contracted rates, Benchmark-indexed, Combination
• Are there pharmacy reimbursement models to support (flat fee, % of AWP/AWP-xx, usual/custom)? Options: Flat dispensing fee, Percentage of AWP, Usual & customary, Custom
• Do you require transition-of-care protections for members when pharmacies leave the network? Options: Yes - transition period required, No, Case-by-case

Operate Mail-Order Pharmacy Fulfillment

• Do you expect mail-order to be mandatory for maintenance meds or optional for members? Options: Mandatory for maintenance, Optional, Preferred with incentives
• What fulfillment SLA do you require for standard and specialty mail orders? Options: Standard: 2-day; Specialty: 5-7 days, Standard: 5-day; Specialty: 10-day, Custom
• Do you require branded packaging, adherence packaging (multi-dose), or clinical labeling services? Options: Adherence packaging, Branded packaging, Clinical labeling, None
• Should mail-order integrate with member portals and refill reminders in real-time? Options: Yes - real-time integration, Preferred but not required, No
• Are there controlled-substance handling, cold-chain, or specialty shipping requirements? Options: Yes - controlled substances, Yes - cold-chain requirements, No
• Do you require inventory reporting and forecast-driven stocking to reduce out-of-stock events? Options: Yes - required, Optional, No

Operate Specialty Pharmacy Dispensing and Management

• Which specialty drug classes or molecules must be supported by the specialty pharmacy?
• Do you require white-glove services (cold-chain, adherence counseling, home delivery)? Options: Yes - full white-glove, Partial (e.g., cold-chain only), No
• Are you expecting clinical outcomes reporting tied to specialty management (e.g., adherence, remission rates)? Options: Yes - outcome metrics required, No, TBD
• Should specialty dispensing include hub integration for patient enrollment and manufacturer support? Options: Yes - full hub integration, Partial integration, No
• What credibility/credentialing or accreditation (URAC, ACHC) do you require for specialty operations? Options: URAC, ACHC, Other, No specific requirement
• Do you require patient affordability solutions (manufacturer copay assistance, PAP facilitation)? Options: Yes - copay assistance, Yes - PAP facilitation, No

Run Specialty Patient Case Management Hub

• Do you want a centralized case management hub for specialty enrollment, benefits investigation, and refill coordination? Options: Yes - centralized hub, No - decentralized, Hybrid
• What degree of clinical engagement is required (nurse outreach, pharmacist counseling, 24/7 support)? Options: Nurse outreach, Pharmacist counseling, 24/7 support, Minimal
• Should the hub manage manufacturer prior authorizations, patient assistance program enrollment, and appeals? Options: Yes - all services, Some services only, No
• Do you require integration between the hub and EHRs, specialty pharmacies, or manufacturer portals? Options: Yes - EHR & pharmacy integration, Manufacturer portals only, No
• What KPIs should the hub report (time-to-enrollment, initiation-of-therapy, abandonment rates)?
• Will the hub be authorized to act as an agent for patient financial assistance or must it only facilitate introductions? Options: Authorized to enroll on behalf, Only facilitate introductions, Undecided

• Statement of Work (SOW)
• Master Services Agreement (MSA)
• Pricing Schedule & Payment Terms
• Performance Guarantees & Remediation
• Rebate Pass-Through Addendum
• Data Access & Integration Agreement
• Data Processing Agreement / BAA
• Acceptance Criteria & Go‑Live Checklist
• Pharmacy Network Transition Plan
• Formulary Transition & Clinical Protocols
• Change Order & Scope Management
• Governance & Communication Charter
• Audit Rights & Compliance Reporting
• Intellectual Property & Licensing Terms
• Termination, Transition & Data Return
• Third-Party Vendor & Subcontractor Annex

• Quarterly Success Review
• Rebate Reconciliation & Transparency Workshop
• Clinical Outcomes & Utilization Validation
• Continuous Improvement Governance & Shared Channel Setup
• Rapid Issue Triage & Remediation Simulation

• Prioritize the initial continuous improvement backlog and assign owners for first experiments.
• Define an auditable reconciliation process and scheduled cadence for future periods.
• Publish final reconciliation statement with supporting extract files and calculation workbook within 5 business days.
• Initiate agreed invoice/credit adjustments and confirm accounting entries with finance teams.
• Implement automated reconciliation report and threshold alerts to the shared channel for next period.
• Current Clinical State (One Sentence)
• Validate whether clinical KPIs and acceptance criteria have been met and document any breaches.
• Identify clinical root causes and approve targeted interventions to improve member outcomes.
• Assign owners for clinical remediation and set measurement checkpoints.
• Produce drill‑down reports for top 5 therapeutic drivers of variance and circulate within 3 business days.
• Implement approved clinical rule adjustments in a controlled test environment and report results at the next checkpoint.
• Notify impacted provider groups and members per agreed communications plan if access or routing changes are enacted.
• One‑Sentence Future State
• Approve governance model and cadences that balance speed of resolution with executive oversight.
• Stand up a shared, auditable communication channel and reporting templates for all stakeholders.
• Opening & Objectives
• Create the shared channel, set access controls, and post onboarding instructions within 2 business days.
• Publish the RACI, cadence calendar, and SLA document to the channel and share with all stakeholders.
• Populate the initial improvement backlog with owners, hypotheses, and success metrics.
• Incident Learning Snapshot
• Confirm triage workflows function in practice and that roles/SLAs are realistic.
• Identify procedural gaps and immediate fixes to reduce time‑to‑resolution for future incidents.
• Ensure staff are trained and confident in using the shared channel and escalation paths.
• Produce a finalized triage SOP and incident playbooks for the top 5 incident types and publish to the shared channel.
• Schedule hands‑on training for operational teams on the shared channel and triage process within 10 business days.
• Implement monitoring alerts for the top 3 incident signals and connect them to the shared channel for automatic triage initiation.
• Ensure shared, unambiguous understanding of current performance against contract KPIs.
• Identify root causes for any shortfalls and agree on concrete remediation with owners and timelines.
• Authorize any financial adjustments or credits and schedule validation checkpoints.
• Deliver a reconciled metric pack (trend, utilization, rebate pass‑through) with source extracts and calculation workbook within 7 business days.
• Assign owners and deadlines for each remediation item; publish a remediation tracker to the shared channel.
• Schedule the next success checkpoint and any interim technical deep dives required for disputed items.
• Pre‑read Confirmation
• Reach mutual agreement on rebate amounts and how pass‑through was calculated for the period.
• Document open disputes, evidence needed, and timelines to resolution.
• One‑Sentence Reconciliation Current State
• Consequence Framing
• One‑Sentence Current State
• Governance & RACI
• Triage Workflow Walkthrough
• Shared Channel Design (Proof)
• Consequence Summary
• Dashboard Walkthrough (Proof)
• Walkthrough of Rebate Calculations (Proof)
• Simulation Scenarios (Execution)
• Metrics Deep Dive (Diagnosis)
• Program Effectiveness & Exceptions (Diagnosis)
• Variance & Dispute Triage (Diagnosis)
• Issue SLA & Escalation Workflow
• Post‑Incident Reconciliation & Learning
• Improvement Backlog & Experimentation Process
• Calibration & Next Steps
• Acceptance Criteria Validation (Decision)
• Settlement & Documentation (Decision)
• Root Cause & Variance Analysis (Proof)
• Cadence & Automations
• Clinical Improvement Plan
• Onboarding & Access Steps
• Decision & Remediation Planning (Validation)
• Next Steps & Follow‑Up Cadence