PBM Audit Areas
| Audit Area | What to Look For | Common Finding |
|---|---|---|
| Pricing guarantees | Are claims processed at contracted rates? | Claims processed above contracted rates |
| Rebate pass-through | Are 100% of rebates passed to the employer? | Rebates retained by PBM |
| Spread pricing | Is spread pricing disclosed and within contracted limits? | Undisclosed spread pricing |
| DIR fees | Are DIR fees passed to the employer? | DIR fees retained by PBM |
| Network compliance | Are claims processed through contracted network pharmacies? | Out-of-network claims processed at in-network rates |
Audit Process
- 1Contract review: Review PBM contract for all pricing guarantees and performance commitments
- 2Data request: Request complete claims data, rebate calculations, and pharmacy invoices
- 3Data analysis: Analyze claims data against contracted rates and guarantees
- 4Discrepancy identification: Identify claims processed above contracted rates or rebates not passed
- 5Recovery demand: Present findings to PBM and demand recovery of discrepancies
- 6Contract improvement: Use audit findings to negotiate improved contract terms
Audit ROI
IQ Insight
PBM audits consistently deliver strong ROI. An independent audit firm typically charges $15,000–$50,000 for a comprehensive PBM audit. Audit findings of 3–8% of pharmacy spend on a $2 million pharmacy budget yield $60,000–$160,000 in recoverable funds — a 3:1 to 10:1 ROI. Conduct a PBM audit every 2–3 years.