CASP Module 31, Section 2: Demonstrating Clinical and Operational Value
MODULE 31: YOUR KEY TO UNLOCKING NETWORK ACCESS

Section 31.2: Demonstrating Clinical and Operational Value

Articulating your “Why”: Developing a compelling value proposition tailored to payers, showcasing how your specialty pharmacy’s clinical programs, adherence support, data reporting capabilities, and patient satisfaction metrics differentiate you from competitors and align with payer goals.

SECTION 31.2

Demonstrating Clinical and Operational Value

Beyond the Application: Articulating Your “Why” to a Skeptical Payer.

31.2.1 The “Why”: Moving from “Credentialed” to “Valued”

In Section 31.1, we completed the most grueling part of your journey: the 18-to-24-month marathon of building your pharmacy, achieving accreditation, and assembling the massive “Document Vault” required for credentialing. You have successfully proven to the payer world that you are not a risk. Your accreditation proves you are clinically competent. Your state licenses prove you are legally compliant. Your financial statements prove you are stable. You have passed the background check.

Now, you will discover a soul-crushing truth: none of that is enough.

You will submit your perfect, 1,000-page application dossier to the PBM, and 90 days later, you will receive a one-sentence email: “Thank you for your interest in our specialty pharmacy network. At this time, our network is closed to new applicants. You may re-apply in 12 months.”

This is the “Great Wall” of specialty pharmacy. This is where most new pharmacies fail. The default answer is always “no.” Why? Because as we established, the PBMs already own the largest specialty pharmacies. They have zero incentive to let you in and compete with their own internal business. From their perspective, their network is not “closed”; it is “optimized.”

This is where Section 31.2 begins. Your credentialing package (Section 31.1) is what gets you permission to knock on the door. Your Value Proposition (Section 31.2) is the battering ram you use to knock the door down. You must now pivot from proving you are safe to proving you are better. You must give the payer a compelling, data-driven, financial and clinical reason to make an exception for you. You must articulate your “Why.”

This section will teach you how to stop thinking like a pharmacist and start thinking like a PBM’s Director of Network Strategy. You will learn to speak their language, which is not the language of pharmacology, but the language of Total Cost of Care (TCOC), Star Ratings, Provider Abrasion, and Member Satisfaction. Your “Value Prop” is your business case, and it must be flawless.

Pharmacist Analogy: The High-Stakes Job Interview

Let’s continue our analogy from the last section. Section 31.1 was you applying for a high-level job (like a Director of Pharmacy). You spent two years getting the advanced degrees (your accreditation), updating your resume (your SOP binder), and passing the extensive background check (your licensure and financials). You have proven you are qualified.

You submit your resume, and the company (the Payer) emails you back: “Thank you, but we are not hiring for this position at this time.” (The network is closed).

You have two choices. You can accept this and go home, or you can find a way to get an interview. You discover the hiring manager (the Payer’s network director) is struggling with a massive problem: their current pharmacy team (the PBM’s internal pharmacy) is making the surgeons (the “prescribers”) furious with constant delays and errors, and their patient satisfaction scores (HEDIS/Star Ratings) are in the basement.

You don’t just resubmit your resume. You build a Value Proposition Deck. You call the hiring manager and say, “I know you’re not hiring, but I need 15 minutes. I’ve built a program that I can prove will solve your surgeon-relations problem and increase your patient satisfaction scores by 10 points in 6 months.”

Now you’ve got the interview. When you sit down, you don’t say, “I’m a really good pharmacist, I’m accredited, and I know my drugs.” Everyone they interview is qualified. That’s the price of entry.

Instead, you present your deck. “Your current team has a 7-day turnaround time, which is causing provider abrasion. My operational model guarantees a 24-hour TAT. Your current adherence rate in oncology is 82%. My high-touch clinical program has a documented adherence rate of 94%. This difference will keep your patients out of the ER, saving you an estimated $500,000 per year for every 1,000 members. Hire me.“

THIS is a value proposition. You have shifted the conversation from “your qualifications” to “their problems” and positioned yourself as the unique, data-driven solution. This is what you must do for the payer.

31.2.2 Deconstructing Payer “Pain Points”: What Do They Actually Care About?

To build a compelling value proposition, you must first have radical empathy for your “customer”—the payer. You must stop thinking about what you want to sell (your pharmacy services) and start thinking about what they need to buy (solutions to their problems). Payers, whether they are a commercial PBM, a Medicare Part D plan, or a state Medicaid MCO, are all judged, measured, and bonused on a few key metrics. Your value proposition must align directly with these “pain points.”

Masterclass Table: Payer Pain Points & How to Solve Them
Payer Pain Point What It Means (Their Internal Monologue) How Your Specialty Pharmacy Can Be the “Solution”
Rising Total Cost of Care (TCOC) “These specialty drugs are bankrupting us. But it’s not just the drug cost. When patients stop taking them, they end up in the ER or hospital, which costs 10x as much. How do I stop the total bleeding?” Your Value Prop: “My adherence program (Pillar 1) keeps patients on therapy, preventing costly hospitalizations. My ‘Waste Mitigation’ protocol (Pillar 2) stops $10,000 in waste. My ‘Site of Care’ program (Pillar 3) moves IV infusion from the hospital to the home, saving you 50%.”
Poor HEDIS / CMS Star Ratings “My Medicare Part D plan’s Star Rating just dropped from 4.0 to 3.5. This means I lose millions in quality bonus payments from CMS. My ‘Medication Adherence for Chronic Conditions’ score is tanking. I need to fix it, fast.” Your Value Prop: “The big-box mail-order pharmacies see patients as a number. My high-touch, pharmacist-led adherence program (PDC > 90%) is specifically designed to identify and resolve adherence barriers. I will be your partner in *personally* managing your non-adherent members and boosting your Star Ratings.”
Provider Abrasion (“Noise”) “My network team is getting 50 angry calls a day from Dr. Smith’s office—our #1 oncologist—because our internal specialty pharmacy (Accredo/CVS) is a ‘black hole.’ They’re threatening to send all their patients to another health plan. This is a five-alarm fire.” Your Value Prop: “I know Dr. Smith’s office. I am local. I will provide a ‘white-glove’ service with a dedicated provider-only line, a <24-hour TAT on all referrals, and a 100% first-call-resolution. I will solve your 'Dr. Smith problem' in 30 days."
Low Member (Patient) Satisfaction “Our member satisfaction scores (CAHPS/HOS) are terrible. Patients feel lost. They can’t get a human on the phone at our specialty pharmacy. They are complaining to their employers (our clients), who are now threatening to leave us for a competitor.” Your Value Prop: “My ‘Care Team’ model provides every patient with a named technician and pharmacist they can reach directly. Our patient satisfaction (NPS) score is +85. We treat your members like family, which reflects positively on you and improves your member retention.”
Lack of Clinical Data “I have claims data. I know *if* a drug was dispensed. I have no idea *why* a patient stopped taking it. Was it cost? Side effects? Did they even start it? I’m flying blind and I can’t manage my drug spend if I don’t know the ‘why’.” Your Value Prop: “I will be your clinical eyes and ears. My data reporting (Pillar 4) goes beyond claims. I will provide you with quarterly reports detailing *why* every single patient discontinued therapy, what interventions my pharmacists made, and what Patient-Reported Outcomes (PROs) we are tracking. I provide clinical intelligence, not just data.”

31.2.3 The Four Pillars of the Payer Value Proposition

Your entire value proposition—your “sales pitch”—must be built upon four pillars of concrete, measurable, and auditable proof. You cannot just *claim* you are better; you must *prove* it. Your “Document Vault” from Section 31.1 was your foundation. This is the structure you build on top of it. A winning value prop integrates all four of these pillars into a single, cohesive story.

Pillar 1: Clinical Excellence

The “What”: Your disease-specific clinical programs, proactive side-effect management, and pharmacist-led adherence interventions.
The Payer Value: Better patient outcomes, improved HEDIS/Star Ratings, higher “days on therapy.”

Pillar 2: Operational Superiority

The “What”: Your speed (Turnaround Time), accuracy (error rates), cold chain integrity, and “white-glove” customer service.
The Payer Value: Reduced provider abrasion, higher member satisfaction, zero drug waste from excursions.

Pillar 3: Financial Alignment

The “What”: Your programs that directly save the payer money, such as site-of-care transfers, waste mitigation protocols, and aggressive financial assistance.
The Payer Value: Lower Total Cost of Care (TCOC), improved member cost-sharing (driving adherence).

Pillar 4: Data & Reporting

The “What”: Your ability to provide clean, customized, and clinically-relevant data that goes beyond standard claims.
The Payer Value: Clinical transparency, actionable insights, and proof that your programs are working (ROI).

31.2.4 Pillar 1 Deep Dive: Building Your “Clinical Excellence” Dossier

This is where you, as a pharmacist, will naturally shine. However, you must translate your clinical skills into the language of payer value. A payer does not pay you to “be a good pharmacist.” They pay you to produce measurable clinical outcomes that improve their quality ratings and lower their total cost of care. Your accreditation (URAC/ACHC) *requires* you to have these programs; this is where you “package” them for a payer.

Tutorial: Building a Disease-Specific Clinical Program (The Payer-Friendly Way)

You cannot be a “generalist” and win. You must pick 1-3 disease states (e.g., Rheumatoid Arthritis, Oncology, Multiple Sclerosis) and build a “Center of Excellence” model. Here is the step-by-step tutorial:

  1. Pick Your Niche: Start with a disease state where you have local provider relationships or staff expertise.
  2. Map the Patient Journey: Create a detailed workflow for a patient in this disease state, from the moment you receive the referral.
  3. Define Clinical “Touchpoints”: Your SOP must define *when* you will proactively contact the patient. This is your “high-touch” model.
    • Touchpoint 1: The Welcome/Onboarding Call (Day 0): Benefit review, financial aid enrollment, education on the drug, set expectations.
    • Touchpoint 2: The “First Dose” Follow-up (Day 3-7): “How did the first injection go? Any injection site reactions? Any questions?”
    • Touchpoint 3: The Mid-Cycle Adherence Check (Day 14): “Just checking in. Have you missed any doses in the last two weeks? Noticed any new side effects?”
    • Touchpoint 4: The Refill Coordination Call (Day 21-25): Confirm adherence, assess side effects, and schedule delivery.
  4. Develop Standardized Assessments (PROs): You must *measure* your interventions. Use standardized, validated questions at each touchpoint.
    • Adherence: “In the last 30 days, how many doses of your [Drug] have you missed?” (Use a non-judgmental tone).
    • Side Effects: “Many patients experience [X, Y, Z]. On a scale of 0-3 (None, Mild, Moderate, Severe), have you experienced any of these?”
    • Clinical Outcome: (e.g., for RA) “On a scale of 1-10, how would you rate your average joint pain this week?”
  5. Create “If-Then” Intervention Protocols: Your clinical value is in what you *do* with the answers. This must be in your SOPs.
    • IF patient reports >2 missed doses, THEN escalate to pharmacist for a 1:1 adherence counseling session using motivational interviewing.
    • IF patient reports “Moderate” side effect, THEN pharmacist provides management tips (e.g., “take with food,” “use hydrocortisone cream”) and faxes a notification to the provider.
    • IF patient reports “Severe” side effect, THEN pharmacist instructs patient to hold dose and contacts provider immediately.
  6. Measure Everything: You now have the data to prove your value. You can generate a report that says: “For our 200 RA patients, we performed 800 proactive clinical touchpoints. We identified 150 side effects, 120 of which were resolved by pharmacist intervention without stopping therapy. Our PDC for this group is 0.92.”
Masterclass Table: From “Standard Service” to “Payer Value Proposition” (Clinical)
Standard Service (What Everyone Claims) Payer Value Proposition (Your Differentiator) How to Prove It (Your “Dossier” Artifacts)
“We counsel patients on their drugs.” “We deploy a proactive, disease-specific clinical management program for your Rheumatoid Arthritis members, resulting in a 12% higher adherence rate (PDC > 0.90) than your current network average.”
  • Your RA clinical program SOP & patient journey map.
  • De-identified data report showing PDC scores for your RA cohort.
  • Your standardized PRO questionnaire.
“We check for side effects.” “Our proprietary PRO-driven side effect management protocol for oral oncolytics identifies and resolves Grade 1/2 toxicities before they lead to dose reduction or therapy discontinuation, improving ‘Days on Therapy’ by an average of 28 days.“
  • De-identified case study of a patient you kept on therapy.
  • Your Oral Oncolytic management SOP.
  • A data report showing discontinuation rates, stratified by reason for discontinuation.
“We have clinical pharmacists.” “Our entire pharmacy staff is 100% CSP-Certified (Certified Specialty Pharmacist) with an average of 10 years of disease-state experience, providing a level of expertise that reduces provider abrasion and improves member trust.”
  • Staff roster with credentials and years of experience.
  • De-identified provider testimonial (“Dr. Smith says…”).
  • Staff training and competency SOPs.

31.2.5 Pillar 2 Deep Dive: Showcasing “Operational Superiority”

Payers and providers are terrified of operational failures. A lost $40,000 cold-chain drug or a 2-week delay in starting therapy is a catastrophic failure that angers providers and harms patients. This is the “Provider Abrasion” pain point. Your value proposition must be built on speed, accuracy, and reliability. The big PBM-owned pharmacies are often large, bureaucratic, and slow. This is your chance to win.

Masterclass Table: From “Standard Service” to “Payer Value Proposition” (Operational)
Standard Service (What Everyone Claims) Payer Value Proposition (Your Differentiator) How to Prove It (Your “Dossier” Artifacts)
“We ship drugs on time.” “We guarantee a < 24-hour Turnaround Time (TAT) on all clean, new referrals and a < 2-hour TAT on all benefit verifications. This eliminates the ‘black hole’ and gets your members on therapy faster.”
  • Your internal TAT report from your Pharmacy Management System (PMS), trended over time.
  • Your “Referral Intake” SOP.
“We ship in coolers.” “We have a 100% validated cold chain process using NIST-calibrated, single-use temperature loggers in every cold chain shipment. Our documented temperature excursion rate is < 0.1%, eliminating product waste."
  • Your “Cold Chain Management” SOP.
  • A sample of a de-identified temperature logger report from a successful shipment.
  • Your “Temperature Excursion” SOP (what you do when it fails).
“We have a call center.” “We provide a ‘white-glove’ provider service with a dedicated provider-only phone line that bypasses all IVR systems and is answered by a live, certified technician. We also use a ‘Care Team’ model, so your members speak to the same team every time.”
  • Call center metrics (Average Speed to Answer < 30 sec, Abandon Rate < 2%).
  • A de-identified “Care Team” workflow diagram.
  • A provider testimonial.
“We have 24/7 service.” “We guarantee 24/7/365 access to a *live, licensed pharmacist* (not a non-clinical answering service) within 15 minutes for any urgent clinical need, as verified by our internal call logs.”
  • Your “24/7 Access” SOP.
  • Your on-call pharmacist’s call log (de-identified) showing response times.

31.2.6 Pillar 3 Deep Dive: Proving “Financial Alignment” (Lowering TCOC)

This is the holy grail. Can you prove to the payer that hiring you will not just cost them money (in reimbursement), but will actually save them money? If you can, you will always get a contract. Your focus must be on Total Cost of Care (TCOC). You are positioning yourself as an investment that provides a positive ROI.

The “Lowest Price” Trap: A Race to the Bottom You Will Lose

As a pharmacist, you’re used to complaining about low reimbursements. It’s a natural instinct to think, “Maybe I can get in the network if I offer to accept a lower rate than CVS.”

This is a fatal, business-ending mistake.

You cannot win this game. The PBMs have pricing leverage with manufacturers that you will never have. They get massive rebates. Their internal pharmacies (Accredo, CVS Specialty) operate on margins you cannot survive on. Trying to compete on drug price (reimbursement) is a death spiral. You will go bankrupt.

Your value is not in being cheaper on the drug; it is in being smarter about the total cost. You must shift the conversation from “drug spend” (your reimbursement) to “medical spend” (the ER visits and hospitalizations you prevent).

Masterclass Table: From “Standard Service” to “Payer Value Proposition” (Financial)
Standard Service (What Everyone Claims) Payer Value Proposition (Your Differentiator) How to Prove It (Your “Dossier” Artifacts)
“We bill for drugs.” “Our Site-of-Care Optimization program actively identifies your members on high-cost, hospital-administered IV drugs (e.g., Remicade, Tysabri) and works with providers to transition them to our accredited home infusion service, saving you an average of $4,000 per member per month.“
  • A de-identified case study of a successful SOC transfer.
  • A financial model showing the cost comparison: (Hospital Admin Fee + Drug Cost) vs. (Your Home Infusion Fee + Drug Cost).
“We have copay assistance.” “Our dedicated Financial Assistance Team has a 98% success rate in securing funding for all eligible patients, ensuring a $0 average patient out-of-pocket. This removes cost as an adherence barrier and is a key driver of our >90% adherence rates.”
  • An internal report showing total $ in financial aid secured for their members (in aggregate).
  • Patient satisfaction quotes/NPS scores.
“We ship the first fill.” “Our ‘Waste Mitigation’ protocol for new oral oncolytic starts includes a mandatory 14-day split-fill. This prevents >$10,000 in drug waste if a patient has an immediate adverse event and must stop therapy. We saved the network an estimated $250,000 last year.”
  • Your “Split Fill / Waste Mitigation” SOP.
  • A financial model showing the savings: (Cost of 30-day fill) – (Cost of 14-day fill) x (% of patients who stop early) = Total Savings.
“We help patients stay on drug.” “Our adherence program doesn’t just improve PDC scores; it directly lowers medical spend. By improving adherence for your CHF members, we can show a 20% reduction in 30-day hospital readmissions for this cohort, saving an average of $14,000 per prevented admission.”
  • This is the most advanced claim, but it’s the most powerful.
  • Requires linking your dispensing data with their medical claims data, which is a key part of contract negotiation (Section 31.4).

31.2.7 Pillar 4 Deep Dive: Leveraging “Data & Reporting” as a Weapon

This is the pillar that holds all the others up. You cannot *claim* you have clinical, operational, and financial value—you must *prove* it with data. The big PBMs have massive amounts of data, but it’s often “dumb” data (just claims). They know a drug was dispensed. They don’t know *why* the patient stopped it, or if they’re experiencing 3 side effects, or if their pain score went from 8 to 2. You can provide this “smart” clinical data that they are blind to. This is your ultimate differentiator. You are their “clinical eyes and ears.”

Tutorial: Building Your “Payer Data Packet”

Your value proposition must be backed by a clean, professional, and customizable data packet. This should be a standard report you can generate quarterly for any payer who contracts with you. Your Pharmacy Management System (PMS) and patient management platform (like Therigy, Asembia-1, or a custom-built tool) *must* be able to capture and report on this.

Your Quarterly Payer Data Packet Should Include:

Part 1: Operational Metrics (Your “Report Card”)
  • Referral Turnaround Time (TAT):
    • Time from Referral $\rightarrow$ Benefit Verification (Target: < 2 hours)
    • Time from Referral $\rightarrow$ PA Submission (Target: < 4 hours)
    • Time from Referral $\rightarrow$ First Fill Shipped (Target: < 48 hours)
  • Call Center Performance:
    • Average Speed to Answer (Target: < 30 seconds)
    • Call Abandonment Rate (Target: < 2%)
  • Dispensing & Fulfillment Quality:
    • Dispensing Accuracy Rate (Target: > 99.99%)
    • Cold Chain Excursion Rate (Target: < 0.1%)
Part 2: Clinical Metrics (Your “Smart” Data)
  • Medication Adherence (PDC):
    • Overall PDC for all their members.
    • PDC, stratified by disease state (e.g., RA, MS, Oncology).
    • PDC, stratified by drug.
  • Therapy Discontinuation Rate:
    • Percentage of patients who discontinued therapy.
    • (Most Valuable Data Point) Reason for Discontinuation: (e.g., 40% due to provider stopping, 30% due to side effects, 20% due to cost, 10% lost to follow-up).
  • Clinical Interventions:
    • Total # of pharmacist interventions made.
    • Interventions stratified by type (e.g., Side Effect Management, Adherence Counseling, Dose Change Recommendation).
Part 3: Satisfaction & Financials (Your ROI)
  • Patient Satisfaction:
    • Patient Satisfaction Score (Target: > 95%)
    • Net Promoter Score (NPS) (Target: > +80)
  • Provider Satisfaction:
    • Annual provider survey results (e.g., “98% of prescribers are ‘Satisfied’ or ‘Very Satisfied’ with our services”).
  • Financial Impact:
    • Total $ in Financial Assistance Secured for their members.
    • Total $ in Waste Mitigated (via split-fills, etc.).

31.2.8 Putting It All Together: The Value Proposition Deck

You will never get a PBM executive to read a 50-page report. All of this data and all these value propositions must be synthesized into a single, professional, and powerful 10-slide presentation deck (e.g., in PowerPoint or as a PDF). This deck is your “battering ram.” It’s what you send to a payer executive to get the meeting, and it’s what you present in that meeting to win the contract.

This deck is your entire business case. It must be visual, data-driven, and concise. It must tell a story.

Masterclass Table: Sample Value Proposition Deck (The 10-Slide Story)
Slide # Title / Headline Content & Purpose (The “Story” Beat)
1 Title Slide [Your Pharmacy Name]: A Clinical Partner in [Payer’s Name]’s Success.
Purpose: Look professional and state your intention.
2 The Problem: A Fragmented & Frustrating Experience “Specialty care is expensive, fragmented, and frustrating for your members and your key providers. The big-box mail-order pharmacies are failing them.”
Purpose: Identify *their* pain points immediately.
3 Our Solution: A “White-Glove” Clinical Model “We are an independent, dual-accredited (URAC/ACHC) specialty pharmacy focused on [Your Niche] with a high-touch, provider-integrated, and data-driven model.”
Purpose: Position yourself as the unique, credible solution.
4 Pillar 1: We Drive Superior Clinical Outcomes (Show a big graph) “Our PDC: 94% vs. Network Average: 82%.”
“Our PRO-driven protocols improve ‘Days on Therapy’ by 28 days.”
Purpose: Hit them with your single best clinical data point.
5 Pillar 2: We Eliminate Provider Abrasion (Show a dashboard) “< 24hr TAT. < 30 sec Avg. Answer Speed. < 0.1% Cold Chain Failure Rate."
Purpose: Prove you are operationally flawless and will solve their “noise” problem.
6 Pillar 3: We Lower Your Total Cost of Care (Show a simple financial model) “Our Site-of-Care program saved the network $1.2M last year.”
“Our Waste Mitigation protocol prevented $250,000 in drug waste.”
Purpose: Prove you are an ROI-positive investment, not a cost.
7 Pillar 4: We Provide Total Clinical Transparency (Show a screenshot of your beautiful, simple data report) “We provide quarterly reports that show you not just *what* we dispense, but *why* patients stop therapy and what interventions we made. We are your clinical eyes and ears.”
Purpose: Show you solve their “data blindness” problem.
8 Proof: What Your Providers Are Saying (Show 1-2 powerful, de-identified quotes) “‘[Your Pharmacy]’s team solved a PA in 2 hours that was stuck with Accredo for 2 weeks. They are a true partner.’ – Local Oncology Practice Manager”
Purpose: Provide the crucial third-party validation.
9 The “Ask” / Partnership Proposal “We are requesting a limited, performance-based specialty contract to service your members in [Your Niche/Region]. We propose a 90-day pilot to prove our value.”
Purpose: Be specific in what you want. Offer a “pilot” to de-risk the decision for them.
10 Thank You / Contact Information Your name, title, and direct contact info.
Purpose: End professionally and open the door for the next step.

31.2.9 The Final Hurdle: How to Overcome “The Network is Closed”

You have your credentialing package. You have your beautiful 10-slide value proposition deck. You email it to the generic “network contracting” inbox at the PBM. You get the same rejection: “The network is closed.”

This is because you are knocking on the front door. The front door is triple-locked. You must find the side doors. You must execute a “flank attack.” Your value proposition deck is not for the PBM’s front-line administrator; it’s for their bosses and their clients.

The “Flank Attack” Strategy: How to Get the “Yes”

Do not waste your time cold-calling the PBM. They are designed to say “no.” You must get *other people* to force the PBM to say “yes.”

Target 1: The Key Prescribers (“Centers of Excellence”)

The Playbook: Go to the biggest, most influential provider offices in your area (e.g., the largest rheumatology or oncology clinic). Give them your “white-glove” service, even if it means losing money on their patients (e.g., taking complex discount cards, filling for free, handling all their PAs). Make yourself indispensable to their office manager.

The “Squeeze”: After 6 months, you ask the office manager: “How much time are we saving you vs. the PBM’s pharmacy?” Then you ask: “Would you be willing to call the PBM’s provider relations rep and tell them you want us in-network?” Now the PBM isn’t hearing from you; they’re hearing from their #1 prescriber, who is angry. This is “Provider Abrasion” in reverse.

Target 2: The Pharmaceutical Sales Reps

The Playbook: Find the local pharma sales reps for the key specialty drugs (e.g., the reps for Humira, Skyrizi, Keytruda). Their bonus is tied to “days on therapy” and new patient starts. They *hate* when their prescriptions get stuck in a PBM “black hole” for 3 weeks.

The “Squeeze”: Show them your 24-hour TAT dashboard. Prove to them you can get their patients on therapy faster than anyone else. These reps have *deep* connections within the PBM and payer world (at the “trade relations” level). They can make introductions and advocate for you as a “preferred partner” who can move their drug.

Target 3: The Employer Groups (The PBM’s *Client*)

The Playbook: This is the ultimate “flank attack.” The PBM’s *true* client is the self-funded employer (e.g., the local school system, the manufacturing plant, the tech company) who *pays* them to manage their benefits. Go to the HR/Benefits Director at that company.

The “Squeeze”: Present your 10-slide deck, but focus entirely on Pillar 3 (Financials). “You are paying [PBM] to manage your benefits, but their internal pharmacy has a 10-day TAT and a 78% adherence rate. This is costing you money in hospital readmissions. Here is my deck showing how my model will lower your company’s Total Cost of Care by 15% and improve your employees’ health.”

The Result: The employer now calls their PBM account executive and says, “Why are you forcing my employees to use your terrible mail-order pharmacy when this local, high-touch pharmacy can save me 15%? I want them in the network. Make it happen.”

This is how you get in. You don’t ask for permission. You create so much value for everyone else in the ecosystem that the PBM is forced, by its own clients and partners, to make an exception for you. Your credentialing package proves you are qualified. Your value proposition proves you are essential.