Services - For Plan Sponsors (PBMAuditors.com)

PBM Auditors.com offers plan sponsors a variety of services.  From the beginning of the contractual relationship to follow up audits, PBMAuditors.com assists clients in:

• Obtaining an analysis of your current PBM contract and finding weaknesses that are leading to 30% costs increases.  Does your contract:
• Allow the PBM's to have total control over generic pricing – up to 60% of your drug spend – without any performance standards?
• Allow the PBM to select an auditor – not the plan?
• Allow for the PBM to control an audit through scope?
• Not allow for rebate audits?
• Have meaningless performance standards that your PBM meets year after year but still leaves you responsible for cost increases?

• Conducting a “Request for Proposal” (”RFP”) by sending out a contract rather than a 200 page questionnaire.  PBM services are a commodity today with all PBMs providing similar basic services.  You pay a consultant to sort through the “good” PBMs and the “bad” ones.  This can be accomplished by sending out the final product – a contract you and your PBM can live with that:

• Clearly states the PBMs responsibilities and the Plan’s responsibilities
• Provides clear terms that are understandable
• Allows the plan sponsor control over pricing
• Avoids the games in the industry
• Requires an annual review of pricing terms
• Defines key terms like rebates, AWP, MAC, generics and brands

• Conducting a claims audit of the PBM.  Many plan sponsors have NEVER conducted an audit of their PBMs.  Without knowing what AWP costs are, do you know if you are getting the discounts promised?  Our audits:
• Verify the AWP with outside pricing guides on the date dispensed for 100% of the transactions
• Verify that the retail, mail order, specialty pricing for brand drugs are taken in accordance with the contract terms
• Verify that the MAC list is performing in accordance with plan provisions or at least at AWP – 65% for retail and AWP – 80% for mail order
• Verify all aspects of plan design including copays, limits, exclusions and prior authorizations
  
  
• Conducting a rebate audit of the PBM.  Yes, rebates can be audited and yes, rebates are increasing in value.  Our audits focus on brand drug rebates – not just what the PBM calls rebates – but all financial benefits from the PBM and Pharmaceutical Company relationship:
• Is the PBM invoicing the correct amounts of rebates to the Pharmaceutical Company?
• Is all of our clients units included in the invoicing?
• Are the rebate contracts favoring the PBM and loosing out on opportunities for the plan sponsor?
• Are all the dollars being passed back to the plan sponsor in accordance with the contract terms?

 

• Performing onsite audits of retail, mail order, specialty and long term care pharmacies.  For over 10 years, POS has conducted onsite audits of pharmacies and desk audits with significant savings for our clients.  Our audits focus on:
  • For desk audits, are there claims submitted by pharmacies that exceed manufacturer dosing or exceed plan design requirements because pharmacies have entered in inappropriate information (i.e. refills too soon or quantity limits)?
  • For onsite audits, has the pharmacy legitimately received, entered, dispensed and given to the patient the correct medication according to the prescription order?  Does the pharmacy have the basics to pass a state audit inspection?

We specialize in services for PBM auditors.