Pharmacy Audits

verify that your prescription drug claims are being paid in accordance with your PBM contract

A MedReview Pharmacy Audit will verify that your prescription drug claims are being paid in accordance with your Pharmacy Benefits Manager (“PBM”) contract. Over the last ten years, expenditures for prescription drugs in the United States have doubled, increasing from 6.1% to 12.2% of national health care costs. The price of drugs is increasing at nearly triple the rate of inflation. In the next five years, the cost of prescription drugs is expected to account for over 15% of all health care costs.

As a result, it is a Best Practice for self-insured employers to perform periodic audits of their PBMs in order to insure that their prescription claims are being paid in accordance with their PBM contracts. The methodology utilized by the drug industry for dispensing and pricing prescription drugs is extremely complex and difficult to understand. A MedReview Pharmacy Audit enables our clients to objectively evaluate the performance of their PBM and to more effectively re-negotiate their PBM contract.

MedReview’s Pharmacy audits evaluate 100% of the prescriptions paid for a one to two year period.  We will evaluate the accuracy of the PBM’s claim adjudication system and financial performance and document any areas where the expected performance does not appear to be in compliance with the client’s PBM contract.  We will verify that the client’s prescription claims are being administered and billed by the PBM in accordance with the client’s plan provisions.  We will also help our client to understand the costs it is incurring with the PBM and will identify possible measure for our client to consider in order to improve plan efficiencies.

Areas in which we find significant contract noncompliance are as follows:

• Generic and Brand discounts applied incorrectly
• Lesser of U&C, MAC, or AWP Pricing not followed
• Dispensing Fees incorrectly charged
• Incorrect Copayments collected
• Terminated Members receiving Prescriptions
• Spread Pricing
• Rebates Incorrectly Calculated and Paid
• Days’ Supply Parameters not being followed
• Excluded Drugs being Covered
• Zero-balance Copayments being charged
• Deductibles and Accumulators not being calculated correctly
• Plan’s Generic Drug Policies not being followed correctly
• Prior Authorization’s and Exceptions to Plan Design not Documented
• Timely Submission and Filing of Claims not followed correctly
• High Dollar Claim limits being exceeded