PBM Audit Services

Pharmacy Benefits and Performance Analysis

Is your Pharmacy Benefit Manager [PBM] acting in your best interests - or their own?
PBMs often hide their major sources of profit:

  • Charging health plan  sponsors more than  they pay  the pharmacy;
  • Retaining over half the  rebate money from drug manufacturers;
  • Overcharging for generics from their ‘captive’ mail order pharmacies.

PBM Contracts - unless properly negotiated - are generally one-sided.
Benefits are often designed to maximize PBM profits at the expense of health plans and recipients.
PBM Audits

  • images/calculator.jpgInspect what you expect;
  • PBMs are often sloppy - or worse - in performing in  accord with contracted terms;
  • Recoveries can be  substantial
  • Pharmacy claim-by-claim audits are feasible since the data is in an industry-standard format.

Our PBM audits are almost always ‘productive’- recovering important dollars for our clients.

Audit & Evaluation Services

Fixed fee evaluation & overview
Claim by claim audits to validate:

            — Pricing accuracy
            — Eligibility of recipients
            — Adherence to benefit design
            — Full and timely rebate payments
            — correct days supply dispensed
            — And more.

Mike Winkelman

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