Key Pricing Guarantees
| Pricing Element | Definition | Audit Check |
|---|---|---|
| AWP discount (brand) | Discount from Average Wholesale Price for brand drugs | Verify claims processed at or above contracted discount |
| MAC pricing (generic) | Maximum Allowable Cost for generic drugs | Verify claims processed at or below MAC |
| Dispensing fee | Per-prescription fee paid to pharmacy | Verify dispensing fees match contracted rates |
| Specialty pricing | Pricing for specialty drugs (often separate guarantee) | Verify specialty claims at contracted rates |
| Mail order pricing | Pricing for drugs dispensed through mail order | Verify mail order claims at contracted rates |
MAC List Manipulation
MAC list manipulation is a common PBM pricing issue. PBMs set MAC prices for generic drugs — the maximum price the employer pays. PBMs can manipulate MAC lists by setting prices above the actual pharmacy acquisition cost, creating spread pricing. Auditing MAC prices against actual pharmacy acquisition costs reveals the spread.
AWP Discount Verification
Pro Tip
AWP discount verification requires comparing the contracted AWP discount to the actual discount applied to each claim. A contract that guarantees AWP-18% for retail brand drugs should show every retail brand claim processed at AWP-18% or better. Claims processed at AWP-15% represent a contract violation. Systematic verification of AWP discounts is the most common source of audit recoveries.