Rx Savings Analysis

Contact Information

First Name

Last Name

Company

Street Address

Street Address Line 2

City

State

Zip

Email

Phone

Customer Information

Who is your Direct Scripts Representative?

Customer

Street Address

Street Address Line 2

City

State

Zip

Phone

Total # of Lives (Members)

Current Rx Spend

In order to complete an in-depth comparison, please provide the rebates received for the same date range as the claims being provided.

Drug Information

Number of Refills Requested

Prior Therapy?

Rebate Information

Mail Date Range Mail Amount of Rebates

Retail Date Range Retail Amount of Rebates

Specialty Date Range Specialty Amount of Rebates

Incumbent PBM

Who is the TPA / Health Insurance Carrier / Health Plan?

Is the plan self-insured or fully insured?

Is PBM carved out and have a separate direct contract with plan sponsor?

What are the current challenges the plan sponsor is having with current PBM?

Is there a formal PBM RFP that has been issued?

Will Consider Launching Off Cycle?

Expected Go Live

Date Range Start for Claims File

Date Range End for Claims File

Quote Due Date

Probability of Order (% of 100%)

***When submitting a claims form, please check for the below fields***

***Mandatory Fields***

  • NDC
  • Quantity
  • Channel
  • Claim Fill date
  • Ingredient Cost
  • Dispensing Fees
  • Member Paid
  • Client Paid
  • NCPDP
  • Days Supply

Field Required for formulary disruption with member impact analysis:

  • Member ID
  • Client Formulary Indicator

Other useful fields

  • Compound
  • UC Indicator
  • COB


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