First Name *

Last Name *

Email *

Phone

How did you hear about us? Benefitpitch BMI Email Continuing Education Conference/Event LinkedIn Shortlister Web Search Word of Mouth Other

I am a(n) * Broker Consultant Administrator Attorney Employer Other

Organization Name *

Organization State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Are you requesting a quote for a Medical plan? * Yes No

# Enrolled Employees * Total # of employees enrolled in Medical plan.

# Plans * Total # of unique Medical plans to be audited.

Annual Spend ($) Total annual spend ($) by plan on Medical claims.

Administrator * TPA processing Medical claims on behalf of the plan.

Timeframe Date range of Medical claims to be audited.

Preferred Methodology Focused Hybrid Random Unknown Select the sample selection methodology that you are interested in.

Concerns Describe any concerns that you may have about the current processing of your Medical claims.

Are you requesting a quote for a Prescription (Rx) plan? * Yes No

# Enrolled Employees * Total # of employees enrolled in Rx Drug plan.

# Plans * Total # of unique Rx Drug plans to be audited.

Annual Spend ($) Total annual spend ($) by plan on Rx Drug claims.

Pharmacy Benefit Manager (PBM) * PBM processing Rx Drug claims on behalf of the plan.

Timeframe Date range of Rx Drug claims to be audited.

Preferred Methodology Focused Hybrid Random Unknown Select the sample selection methodology that you are interested in.

Rebate * YesNo If the PBM contract allows a rebate audit, are you interested in including one in this quote?

Financial Guarantee * YesNo If the PBM contract allows for a financial guarantee audit, are you interested in including one in this quote?

Concerns Describe any concerns that you may have about the current processing of your Rx Drug claims.

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