UNAPOLOGETIC PHARMACY CONSULTING SOLUTIONS

WE DON'T
JUST AUDIT.

WE AUTOPSY
UP PAST OUR
ELBOWS.

Expert Pharmacy consulting to optimize costs, compliance, and patient outcomes.

We’re not here to be liked. We’re here to be right.

Our team is a crew of misfit economists, PharmDs, regulatory experts, and ex-PBM insiders who know where the bodies are buried — some of us still have the shovels.

Bespoke Solutions Built for the Bold

We didn’t build Prism to play the same game as the big box firms. We built it to break the rules that keep employers overpaying and PBMs underdelivering. Every solution we offer is designed to do one thing: make pharmacy benefits enforceable, transparent, and clinically sound — without compromise.

PBM Procurement

Procurement Done Right — All the Pageantry, None of the Loopholes. We design a purchasing process that feels custom because it is — curated RFP strategy, predications that lock in expectations, and qualitative scoring before financials hit the table. Every promise becomes a clause. Every clause becomes leverage.

Audit & Recovery

We Don’t Just Audit. We Autopsy.
Our audits trace every rebate, discount, and definition back to its source, exposing leakage others miss. Then we wire the fix into your contract so it sticks. We deliver more than a report — we deliver peace of mind.

Contract Negotiation

If It Isn’t Enforceable, It Isn’t Real. We negotiate like the people who will have to audit it — because we are those people. Every clause is pressure-tested, every definition locked down, every guarantee built to bite. If it isn’t enforceable, it isn’t real — and we make it real.

Clinical Strategy

Our clinicians dig into plan design, utilization edits, and clinical programs to ensure what was sold is what’s being delivered. From biosimilar adoption to GLP‑1 governance, we enforce evidence‑based criteria and contractual commitments so your strategy isn’t just documented — it’s operational and defensible.

Data & Analytics

Dashboards Don’t Lower Costs. Decisions Do. Dashboards don’t lower costs — decisions do. Our RxKai reporting turns noise into action, showing you what to change, by when, and why it pays. Every insight is paired with execution, so the math moves the market — not just your next meeting.

340B Program Management

340B Isn’t a Side Hustle. It’s a Compliance Regime With Teeth. We build 340B programs that regulators respect and CFOs celebrate, with controls that survive audits and deliver measurable value. Every safeguard is engineered to protect your eligibility and your savings.

PBM Procurement Done Right

Prism deploys the best of the best – a cross‑functional squad of crack procurement strategists, health economists, former PBM pricing and network leads, PharmDs, and a contracts SWAT team – to run a thoughtful partner search that’s surgical, yet not sterile.

We start with a Blueprint to set mission and define non‑negotiables, translate them into predications and expectations (no wiggle‑words), and deliberately withhold financials until qualitative truth is weighted and scored.

Then we force what’s sold into what’s signed – line‑by‑line definitions, hard and fast financial guarantees, operational remedies — so bidders can’t hide behind deck speak and finalist meeting ‘fast talk’.

And because we refuse misaligned commissions and under the table offsets and can put fees at risk on a 1:1 ROI when scope allows, everyone knows exactly who we work for.

We’re built for employers and covered entities that want enforceability – and for PBMs who deploy best practices. If a competitor tells you our approach is “too aggressive,” ask them why enforceable terms make them nervous.

How we overdeliver (the kitchen sink):

Blueprint workshop → predications → RFP → Contract Deviation Assessment → finalist gauntlet → contract redline with teeth.
Quality & Contract assessments first, money second – qualitative scoring before financials to stop price theater from erasing service risk.
Scenario modeling using our independent pricing intelligence and proprietary analytics engine — not vendor‑colored assumptions.
Explicit treatment of “gotcha” definitions (brand/generic, MAC, U&C, specialty, GLP‑1 handling, channel crossover).
TrueCost / CostVantage / Lowest Net Cost impact analysis and auditability plan — before you sign, not after you’re stuck.
Fee transparency attestation — no Private Equity, no parent firms, no hidden incentives – just a crack team of independent and fanatical pharmacy geeks.

Word for the wise…If your “independent” pharmacy consultant is owned by a brokerage, tech company, or private equity group, enjoy the ‘alignment talk’ — you’ll pay for it in the definitions.

Financial Audit – (Rebate / Network Discount / Administrative Fee / Benefit Setup)

PBM Procurement Done Right

Our PBM autopsy (audit) team is built like a forensic lab — economists, rebate operations alumni, benefit coders, claims analysts, and former PBM grifters — all obsessed with tracing every penny from PBM to plan.

We don’t summarize; we dissect. We challenge the rebate math, assess guarantees against your actual mix, surface definition games and channel leakage, then calculate and help to collect what’s owed — then we amend the contract so the fix sticks.

We also run stand-alone benefit, MAC, and discount reconciliations when you need precision strikes.

Competitors deliver book reports. We deliver coroner’s reports — and wire the remediation into governance.

How we overdeliver (the kitchen sink):

Rebate revenue lineage mapping, cross-matching formulary placement, definitions, and class-of-trade shifts.
Discount and guarantee validation with year-end true-up and interest where applicable.
Benefit code audits — prior-auth logic, step-therapy rules, accumulators, day-supply, DAW impacts.
MAC and specialty spread analysis; ingredient cost vs dispensing fee integrity checks.
Corrective action plan that becomes contract addenda — not a PDF that gathers dust.

Word to the wise – If your pharmacy consultant’s last “audit” ended with “monitor going forward,” they audited your patience — not the math.

PBM Contract Negotiation & Enforcement

PBM Procurement Done Right

You don’t get what you deserve –

You get what you negotiate.

Contracting Excellence is the backbone to Prism’s success. Said plainly, we negotiate like the people who will have to audit it — because we are those people. Former PBM contract owners and benefit engineers sit with our team of ERISA attorneys and economists to weaponize words against PBM’s into enforceable language, collapse “agree with exception” hedges, and establish performance guarantees that bite.

Our goal isn’t to be liked — it’s to be right — and to leave you with a contract that resists creative interpretation by those PBM’s that aim to try their luck.

Partnership is great. Aligned incentives are better. We fix root cause at the clause, so your outcomes aren’t hostage to vibes and quarterly targets.

How we overdeliver (the kitchen sink):

Clause‑by‑clause redline matrix with risk, remedy, audit path, and owner for every section.
Definitions tightened to close common games: DAW, WAC/AWP drift, U&C, specialty routing, channel reassignment, rebate exclusions, and credit language impacts.
Governance pack — escalation ladders, cure periods, and data‑access SLAs baked in.
Performance guarantee catalog with auto‑pay mechanisms, not “negotiate later.”

Word to the wise – “Strategic partnership” is not a remedy. Contract language is.

Data Analytics & Outcomes Based Insights

PBM Procurement Done Right

Our analytics crew blends healthcare economists, data scientists, and PharmDs with a not-so-secret advantage — ex-PBM insiders who know where definitions hide and where the value leaks.

We built our wholly owned and operated proprietary data stack to provoke action, not mesmerize with gradients: quantify exposure, rank levers, calculate trade-offs, and push the decision into contracting, clinical policy, or procurement.

That’s the ethos behind RxKai and our data hungry mindset — clarity that moves money and outcomes.

We pair that with independent pricing benchmarks (MediSpan, NADAC, etc.) and our battle-tested proprietary modeling framework so we’re not borrowing a PBM’s ruler to measure the PBM and their performance. Said plainly, ‘competitors’ lead with portals; we lead with verifiable inputs and execution bias.

How we overdeliver (the kitchen sink):

SOC audited and compliance tempered proprietary infrastructure ensures ill equipped clowns aren’t juggling your precious data.
Cohort-level net cost modeling with sensitivity bands by channel, class, and utilization controls.
High-cost claimant journey mapping — clinical + financial threading to target interventions.
Action briefs instead of vanity dashboards — what to change, by when, with expected yield.
GLP-1, biosimilars, and CGT stress tests tied to contracting levers, not blog posts.
Lead-indicator KPIs aligned to guarantees and clinical criteria, so reports trigger money — not meetings.

Word to the wise – If a glossy portal could fix pharmacy, it would have been done by now.

340B Program Management & Compliance

PBM Procurement Done Right

340B is not a side hustle — it’s a compliance regime with teeth. Our team includes hospital operations vets, covered‑entity administrators, auditors, and data specialists who build programs that survive an audit, maintain compliance, and deliver compounded 340B savings.

From Program Blueprint to policy stack to ongoing governance to contract pharmacy expansion – we engineer controls you can defend — and yes, we’ve done it in places most avoid, including correctional health, where advocacy, documentation discipline, and vendor management are non‑negotiable.

Anyone can talk “maximize savings.” We protect eligibility, harden documentation, and design monitoring that catches edge‑case exceptions before regulators do. That’s how you keep the program — and the savings.

How we overdeliver (the kitchen sink):

Full program blueprint — policy, SOPs, eligibility logic, and data lineage mapping.
Validation and forensic audits with corrective action plans wired into daily workflows.
Contract pharmacy oversight — material‑breach provisions, data access standards, and reconciliation cadence.
Referral capture and mixed‑use controls; accumulator checks; provider file hygiene.
Advocacy playbook for niche environments (e.g., DOC) where policy and politics collide with pharmacy reality.

Word to the wise – If your advisor treats 340B like a revenue hack, you’re the one on the hook when the auditors arrive.

Clinical Insights & Program Management – Spectra360

PBM Procurement Done Right

We believe you don’t need to buy a whole bunch of new programs and services from your PBM – rather, we believe clinical best practices begins with simply making sure the PBM is doing the job you hired them for.

Our clinical bench is built like a strike team — PharmDs, outcomes researchers, specialty pharmacists, health economists, benefit coders, and ex‑PBM clinical policy owners. We start by standing up our clinical Spectra operating model that assigns a dedicated Prism clinician to baseline your formulary, benefit design, and claims edits, then hard‑wires best practices into plan policy, utilization criteria, and day‑to‑day governance. This isn’t advisory theater — it’s a build‑and‑run program designed to prevent waste, close clinical gaps, and drive lowest net cost without sacrificing outcomes.

From there, we move fast where the money moves: biosimilar exclusivity for Humira and Stelara with proactive member transitions; asking the hard net‑cost questions PBMs dodge; and pressing for biosimilar‑first steps across related biologics when clinically appropriate. Translation — originator brands are non‑covered unless a tight exception applies, and new starts route to the lowest net‑cost agent by default.

We also police the GLP‑1 gold rush with discipline: detect GLP‑1/DPP‑4 overlaps and kill them; clamp the first 90 days to 28‑day fills; and secure manufacturer assistance when the PBM can actually apply it. It’s evidence‑anchored, cost‑aware, and implementation‑ready.

And because dashboards don’t lower costs — decisions do — we pair this with RxKai reporting so your team gets an action brief, not a vanity graph. You’ll see what to change, by when, and the yield we expect — then we push those decisions into contract language and UM criteria so they stick.

What “overboard” looks like (our kitchen‑sink playbook)

Clinical Spectra baseline — then perpetual motion

End‑to‑end review of formulary, clinical programs, claim‑level edits, preventive lists, and coverage policies; we publish specific recommendations your PBM can actually operationalize.

Strong stances where they matter: DAW penalties, compound controls, OTC/sexual‑dysfunction exclusions unless you opt in, and sensitive categories (gender identity, infertility, abortifacients) mirrored cleanly to your SPD with lowest‑net‑cost logic.

A named Prism clinician stays on the file — fielding benefit decisions, evolving policy, and holding the PBM to clinical best practice week‑over‑week.

Insider Advantage

Relentless Execution

0 M

Member Lives Under Management

Over 5 million patients served, translating to significant healthcare savings every year.

0 %

Uncomfortable Truths

We don’t tiptoe. We interrogate contracts, expose games, and force clarity. PBMs won’t love us. You will.

0 %

Average Annual Savings

Prism has a 1:1 Return on the initial Investment on all dollars paid in the first year

0 +

Dedicated Staff

Our continually growing team is here to support and enforce every aspect.

Proof Over Promises

Unfiltered feedback from those who’ve seen Prism deliver, not just consult.

"We didn't believe this kind of savings was possible. If it weren't for Prism, we would be stuck in a dead-end contract, and unable to make exciting changes to serve our members. They're the real deal."

" The Prism team maintains and brings a high level of pharmacy benefit expertise and collaboration to a PBM analysis. A top-notch team with demonstrable depth and breadth. The team leaders are always accessible."

"The Prism team brings an excellent team dynamic to their work – beginning with authentic humility, the team always brought thoughtful, strategic and "always listening"

"The Prism team can flat out negotiate for results. Prism's pinpoint focus plus strong command of contracts, rebates, services and everything else that involves extracting an artful balance of deep cost reduction value yet "big fish, small pond"

“The Prism Health Group helped us secure a future we didn’t believe was possible. Our hospital serves a volatile population that deserves increased access to quality care, community outreach programs, and services that help ensure healthy and happy lives.”

Our Mission

We built the playbooks PBMs use—now we use them against the PBMs. No spin. No cozy relationships. Just results.

We’re dedicated to transforming healthcare through innovative PBM strategies. By optimizing costs and ensuring compliance, we aim to empower healthcare stakeholders to make informed choices. Join us in redefining pharmacy benefits for a healthier tomorrow.

MEET OUR LEADERSHIP TEAM

The Minds Behind the Mission

Prism’s team is a rare breed — part strategist, part enforcer, all in. We’ve assembled a crew of economists, clinicians, data scientists, and ex‑PBM insiders who know the system inside out — and how to beat it. They’re the reason we can promise what others can’t: independence with consequences.