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.
To begin the pharmacy claims audit process, we request an electronic claims file of 100% of the prescriptions paid by the PBM during a certain period of time (usually two years). With MedReview’s electronic software, our pharmacy claims audits review every prescription in the file for the following:
|•||Were the correct dispensing fees applied to the client’s prescription claims?|
|•||Were any branded products used when a cheaper generic substitute was available? If so, what was the cost to the plan?|
|•||Was the client overcharged for any prescriptions versus the pricing schedule contained in its PBM contract?|
|•||Were any products billed to the client that were not covered by its plan or that had coverage limitations?|
|•||Was the client’s mail-order program working effectively?|
|•||Were all manufacturer rebates, as specified in the client contract with the PBM, paid to the client?|
MedReview’s Pharmacy Audits are fixed fee audits. The amount of the fee will be based upon the number of employees in your plan.