We often hear the question “What should be included in a comprehensive audit?” Pharmacy benefits are complex. To address the myriad of issues faced by the plan sponsor, a comprehensive audit should include:
- Financial contract elements like negotiated discounts, MAC list application, dispensing fees, Administrative fees, etc.
- Plan Design with a focus on copays, coinsurance, deductible, clinical programs, prior authorizations, quantity limits, and excluded drugs.
- Clinical programs that include proper application of prior authorizations, quantity limits, excluded drugs, and step therapy.
- Eligibility looking at all claims filled by eligible members on data of fill.
- Rebates to assess the financial and procedural accuracy of rebate reimbursement based on the contract.
- Performance Guarantees to validate the service guarantees in the contract, customer service answer times, mail service days to fill and delivery, etc.
We recommend that if the plan has never audited the PBM, decision makers should focus on the audits that offer the greatest return. Financial contract audits plus plan design and clinical program audits typically offer the greatest return and are where we see the most PBM errors.
For more information on pharmacy benefit audits or CobaltRx, please give us a call at 225-927-1940.