Specialty Drug Audit Areas
| Audit Area | What to Look For | Common Finding |
|---|---|---|
| Specialty pharmacy compliance | Are specialty drugs dispensed through contracted specialty pharmacies? | Claims dispensed through non-contracted pharmacies |
| Specialty pricing | Are specialty drugs priced at contracted rates? | Claims priced above contracted rates |
| Specialty carve-out compliance | Are specialty carve-out drugs directed to the carve-out pharmacy? | Carve-out drugs dispensed through PBM specialty pharmacy |
| Specialty rebates | Are specialty rebates passed to the employer? | Specialty rebates retained by PBM |
| Specialty utilization management | Are specialty drugs subject to appropriate UM? | Specialty drugs dispensed without required prior authorization |
Specialty Carve-Out Compliance
Specialty drug carve-outs direct specialty prescriptions to a specific specialty pharmacy — often one that offers better pricing than the PBM's owned specialty pharmacy. Carve-out compliance audits verify that specialty drugs are actually being dispensed through the carve-out pharmacy. PBMs sometimes route carve-out drugs through their own specialty pharmacy — violating the carve-out agreement.
Specialty Audit Value
IQ Insight
Specialty drug audits are the highest-value pharmacy audit area. Specialty drugs represent 50–60% of pharmacy costs — and specialty drug pricing is often less transparent than retail pricing. A specialty drug audit that finds 5% of specialty claims priced above contracted rates on a $1 million specialty spend recovers $50,000. Specialty drug audits should be conducted annually.