PHARMACY AUDITS

Each year, your group health plan pays for thousands of prescription claims. Pharmacy claims now account for about 25% of all group health plan expenses. Yet, without conducting an audit, you have no way of knowing whether or not you are being billed correctly by your PBM firm for these claims.

A MedReview Pharmacy Audit covers a twelve, eighteen, or twenty-four month period and covers every single prescription claim billed to you during that time. Our audits are not based on just a sampling of claims.

Pharmacy Audits cover the following key areas:

• Was the prescription billed to you at the rate specified in your PBM contract? Was the correct AWP figure used for billing to you and did you get the correct discount from AWP?
  
  
• Was the correct dispensing fee billed to you for each prescription?
  
  
• Could a generic product have been used instead of a branded product?
  
  
• Were there prescriptions where a generic substitute could have been used but was not used? If so, was the generic substitute refused by the patient or by the physician? What was the cost to your plan of the generic substitutes not being used?
  
  
• Were you billed for any drugs not covered by your plan?
  
  
• Is your mail-order program saving your plan money or costing your plan money?
  
  
• Did you receive all rebate monies from the pharmaceutical manufacturers that you are entitled to receive from the PBM?

In addition, each Pharmacy Audit includes a summary of your claims activity during the audit period. We also illustrate for you the average cost per claim, the cost per claim of retail versus mail-order, and the cost per claim of branded products versus generic substitutes.

Pharmacy Audits are conducted on a fixed fee based on plan size.