Pharmacy Audits

 


A MedReview's Pharmacy Audit will verify that your prescription drug claims are being paid in accordance with your Pharmacy Benefits Manager ("PBM") contract.


The alarming increase in the cost of prescription drugs, combined with the proliferation of new drugs in the marketplace, makes Pharmacy Audits a necessary tool of plan management.


MedReview's Pharmacy Audits are fixed fee audits. The amount of the fee will be based upon the number of employees in your plan.


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?
  • Were any branded products used when a cheaper generic substitute was available? If so, what was the cost to the plan?
  • Were all prescriptions paid according to the pricing schedule contained in the PBM contract?
  • Were any prescriptions paid for drugs not covered by the plan or that have coverage limitations?
  • Is the mail-order program functioning effectively?
  • Did the plan receive all pharmacy manufacturer rebates from the PBM that it was entitled to receive under the contract?

In addition, the Pharmacy Audit report includes a summary of claims activity during the audit period, 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.


Because of the volume of prescription drug claim payments that occurs in any pharmacy benefit program, we find a large number of errors in the Pharmacy Claims Audits we perform. A recent pharmacy audit uncovered over 7,000 retail prescriptions and over 4,000 mail order prescriptions in which the PBM had over-charged the plan sponsor for dispensing fees. In the same Pharmacy Audit, we discovered over 12,000 prescription claims that had been charged to the plan at higher rates than specified in the PBM contract.