Decision Question This Instrument Addresses
"Are our pharmacy costs rising because of fraud – or because our formulary, PBM execution, and SFDA traceability are misaligned in ways that inflate costs while remaining technically compliant?"
Each dimension targets a specific failure mode that causes decisions of this type to go wrong. The instrument surfaces the gaps most likely to be consequential: not maturity against an idealised standard.
Formulary Governance
Is your formulary enforced, clinically current, and aligned to your actual prescribing population – or are there systematic deviations that are neither flagged nor corrected?
PBM Execution
Are your PBM controls preventing compliant leakage – or are they creating the conditions for it through pricing arbitrage, substitution incentives, and adjudication gaps?
SFDA Traceability Alignment
Is your track-and-trace compliance generating the operational intelligence required to identify leakage sources – or is it a reporting obligation without analytical value?
Prescribing Pattern Analysis
Are there systematic deviations from formulary, substitution patterns, or prescribing concentrations that create cost exposure independent of fraud detection?
Loss Ratio Attribution
Can you distinguish between pharmacy loss driven by structural misalignment and pharmacy loss driven by individual non-compliance – at a level of granularity that supports corrective action?
Typical Audience
Payer CMOs, CFOs, Pharmacy Directors, Compliance Officers, Health Insurance Actuaries