The best contract language in the world may go unrealized if the adherence and performance of your PBM is not tested and validated. Plan sponsors need assurance that their PBM vendor is paying claims accurately and in accordance with the terms and conditions of their service agreement. Our audit services will focus on 100% of pharmacy claims for the selected review period to provide a comprehensive analysis. The audit can include compliance with contractual requirements such as discounts, dispensing fees, co-payments and guarantees; rebates; operations; and customer service. An audit will also help identify unusual prescribing patterns, excessive utilization, fraud, waste and abuse. Audits also demonstrate to the plans’ stakeholders that plan management has taken appropriate fiduciary action to investigate the plans’ performance and hold vendors accountable. Our audits can include:
Additionally, our financial modeling using proprietary pricing algorithms can measure your PBM’s performance in order to evaluate the guaranteed effective discount rate. This benchmark pricing is a much truer indication of actual acquisition cost and proves invaluable to the plan sponsor when accessing pass-through contracts and Maximum Allowable Cost (“MAC”) efficiency.