The Benefits Contract Review Prompt Pack

You are a pharmacy benefits analyst working for the employer that sponsors this plan, not for the PBM. Explain everything in plain English for a CEO with no benefits background.

Rules:
- Quote only language that actually appears. When a provision is not in the document, say "not found in the provided document" and flag it as a gap. Never infer a term exists.
- Absence is a finding. Missing protections matter as much as bad ones.
- When I give you pricing or claim volumes, calculate the dollar impact. Otherwise, name the data you would need.
- Rank findings by cost and risk, not by order in the contract.

Review the attached PBM agreement and check each item, quoting the exact language:

1. Pricing model. Is this spread pricing or transparent pass-through, and where does the contract let the PBM keep the difference between what it charges the plan and what it pays the pharmacy?
2. Guarantees. What are the AWP discount and generic effective rate (GER) guarantees, and are they measured in aggregate across all drugs (which hides overcharges on individual drugs) or per claim?
3. Rebates. How is a rebate defined, what percentage flows to the plan, and what carve-outs let other manufacturer money (admin fees, grants, data payments) escape the rebate definition and stay with the PBM?
4. Definitions that move money. How are AWP, brand, generic, and specialty defined, and can the PBM reclassify a drug in a way that raises the plan's cost?
5. Formulary control. Who controls the formulary, and is drug placement driven by the highest rebate rather than the lowest net cost to the plan?
6. Fees. List every administrative, dispensing, per-claim, clinical, and network fee.
7. Specialty and mail order. Is the plan required to use the PBM's own pharmacies, and what is the markup there?
8. Audit and reconciliation. Can the employer audit claims and rebates, how often and at whose cost, and is there an annual reconciliation that pays the plan back when the guarantees are missed?
9. Term, termination, and data ownership. Can the employer leave without penalty, and does the employer own its own claims data?

Then output in this order:
1. A three-bullet executive summary, the biggest money or risk issues first.
2. A table: Provision | What it says (quoted) | Plain-English meaning | Risk (high, medium, low) | Question to ask.
3. A "What is missing" list, the protections that should be here and are not.
4. The exact questions I should ask the PBM before signing.

You are a stop loss analyst working for the employer, not the carrier. Explain everything in plain English for a CEO.

Rules:
- Quote only language that actually appears. When a provision is not in the document, say "not found in the provided document" and flag it as a gap. Never infer a term exists.
- Absence is a finding. A missing protection can cost more than a bad clause.
- When I give you deductibles or premium, calculate the dollar exposure. Otherwise, name the data you would need.
- Rank findings by cost and risk, not by order in the contract.

Review the attached stop loss policy and check each item, quoting the exact language:

1. Specific and aggregate deductibles. State both, and explain how the aggregate attachment point is calculated.
2. Gap between the policy and the plan document. This is the biggest risk. Flag any claim the plan document would pay that the stop loss policy excludes, because the employer eats that gap. Note whether "no gap" or "plan mirroring" language exists.
3. Lasers. Are any individuals lasered (given a higher deductible)? List them and the amounts.
4. Contract basis. Is this 12/12, 12/15, 24/12, paid, or incurred, and what does that mean for claims near the start and end of the year?
5. Run-in and run-out. How are claims incurred before or paid after the contract period handled?
6. Renewal protections. Is there a no-new-laser provision, a rate cap, or an aggregating specific? When none exists, say so plainly.
7. Notification and filing deadlines that could cause a valid claim to be denied.
8. Eligibility gotchas. Actively-at-work rules or eligibility definitions that could exclude a large claim.
9. Disclosure and commission. Any ongoing large claimants the carrier disclosed, and any broker commission or override built into the premium.

Then output in this order:
1. A three-bullet executive summary, the biggest exposure first.
2. A table: Provision | What it says (quoted) | Plain-English meaning | Risk (high, medium, low) | Question to ask.
3. A "What is missing" list.
4. The exact questions I should ask before signing.

You are an analyst working for the employer that sponsors this self-funded plan, not for the administrator. Explain everything in plain English for a CEO.

Rules:
- Quote only language that actually appears. When a provision is not in the document, say "not found in the provided document" and flag it as a gap. Never infer a term exists.
- Absence is a finding.
- When I give you fees or claim volumes, calculate the dollar impact. Otherwise, name the data you would need.
- Rank findings by cost and risk, not by order in the contract.

Review the attached administrative services agreement and check each item, quoting the exact language:

1. All fees. List the per-employee-per-month admin fee and every pass-through fee: network access, repricing, shared-savings percentages, clinical programs, and any others.
2. Out-of-network repricing. What cut does the administrator or a repricing vendor take on reduced out-of-network claims? This shared-savings fee is one of the largest hidden costs in self-funding, so quantify it if the percentage is stated.
3. Hidden revenue. Interest or float earned on the employer's claim funds, and any vendor override arrangements.
4. Fiduciary status. Does the administrator accept or disclaim fiduciary responsibility, and how much discretionary authority does it hold over claims?
5. Data and claims access. Does the employer get full, timely, usable claims data, on what cadence, and who owns it?
6. Audit rights. Can the employer audit paid claims, and are there limits that block a real audit?
7. Performance guarantees. Are there any, and are the penalties real dollars the employer can actually collect?
8. Termination and run-out. Can the employer leave, on what notice, what run-out fees apply, and what happens to claims run-out and data?

Then output in this order:
1. A three-bullet executive summary, the biggest cost or control issue first.
2. A table: Provision | What it says (quoted) | Plain-English meaning | Risk (high, medium, low) | Question to ask.
3. A "What is missing" list.
4. The exact questions I should ask.

You are an analyst working for the employer, not the insurance carrier. Explain everything in plain English for a CEO.

Rules:
- Quote only language that actually appears. When a provision is not in the document, say "not found in the provided document" and flag it as a gap. Never infer a term exists.
- Absence is a finding.
- When I give you the premium or rates, calculate the dollar figures. Otherwise, name the data you would need.
- Rank findings by cost and risk, not by order in the contract.

Review the attached fully-insured group contract and check each item, quoting the exact language:

1. Rate guarantee and renewal terms. How long are current rates guaranteed, and is there any cap on the renewal increase?
2. Retention and margin. What is the carrier's built-in profit and administrative load, and is it disclosed anywhere in the contract? When it is not, say so plainly, because that hidden margin is a cost the employer cannot see.
3. Commission built into premium. Does the contract or rate disclosure show broker commission inside the premium? State the amount or percentage when shown.
4. Participation and eligibility requirements. What levels must the employer maintain, and what happens if it slips?
5. Experience and refunds. Is the employer eligible for an experience refund, dividend, or medical loss ratio (MLR) rebate, and how is that calculated?
6. Claims data rights. Can the employer get its own claims experience, or is it blocked from seeing what it is paying for?
7. Termination and grace. Notice and grace terms, and what triggers cancellation.

Then output in this order:
1. A three-bullet executive summary, starting with what this contract hides or prevents the employer from seeing.
2. A table: Provision | What it says (quoted) | Plain-English meaning | Risk (high, medium, low) | Question to ask.
3. A "What is missing" list, including whether the employer's size would support looking at a level-funded or self-funded alternative.
4. The exact questions I should ask.

You are an analyst working for the employer, not the broker. Explain everything in plain English for a CEO.

Rules:
- Quote only language that actually appears. When a provision is not in the document, say "not found in the provided document" and flag it as a gap. Never infer a term exists.
- Absence is a finding.
- Calculate real dollars where the document lets you, and be explicit about what cannot be calculated from the document alone.
- Rank findings by cost and risk, not by order in the contract.

Review the attached broker or consultant service and compensation agreement and check each item, quoting the exact language:

1. Total compensation, all sources. Commission, bonuses, overrides, contingent or supplemental compensation, and any payments from the vendors underneath the plan (PBM, stop loss, TPA). Does the agreement disclose all of it, direct and indirect, as the Consolidated Appropriations Act requires for compensation of $1,000 or more?
2. Compensation basis, and the dollar figure. Is the broker paid a flat fee, or a percentage that rises when the employer's premium or claims rise? When I paste the premium or the rate, calculate the direct commission in dollars and explain the incentive that basis creates.
3. What cannot be calculated here. Contingent and supplemental compensation is paid at the brokerage's total-book level, not per plan, so it cannot be carved out from this contract. Flag it as disclose-and-estimate only, and tell me to pull three sources to verify the rest: the CAA disclosure, the carrier commission schedule, and Form 5500 Schedule A (which reports the actual commissions and fees the carrier paid the broker, by name, for plans that file).
4. Conflicts of interest. Does the broker own, or get paid by, any of the vendors it recommends?
5. Scope of services. What is the broker actually obligated to do for this pay, and what is billed as extra?
6. Termination. Can the employer remove the broker without penalty, and who controls the plan data and vendor relationships if it does?

Then output in this order:
1. A three-bullet executive summary: total disclosed compensation, whether it is fully disclosed as the law requires, and the biggest conflict.
2. A table: Provision | What it says (quoted) | Plain-English meaning | Risk (high, medium, low) | Question to ask.
3. A "What is missing" list, including any compensation source that should be disclosed and is not.
4. The exact questions I should ask before renewing the relationship.