PBM Auditing

Why Audit My PBM?

If you are wondering if your PBM is processing your claims according to your instructions, or wondering how the many news releases of PBM lawsuits could affect your situation, you are not alone. The answer is to allow us to perform a claim by claim retrospective audit of your PBM. It is standard in the industry and provided for in your PBM Services Agreement.

The result of the audit exposes all facets of the processing of your claims, may result in a restitution payment and will increase your understanding of your pharmacy expense.

Here are Examples of Audit Errors:

  • Inaccurate application of MAC Pricing
  • Selection of wrong AWP dollar amount for calculation of cost
  • Late application of First DataBank or Medispan updates to AWP Pricing
  • Inaccurate assignment of Brand / Generic label (missing deserved contract discount)
  • Missing generic substitution copay penalty or disregard of Dispense As Written rule (DAW 0) as a substitutable brand and therefore not applying the penalty
  • Improper use of First DataBank’s “Baseline” pricing for contracted discounts
  • Allowing “excluded” drugs to process without a proper Prior Authorization
  • Missing contracted “guarantees” on discounts and dispensing fees
  • AWP % discount guarantees hedged due to claims with extremely high AWP $ assignments
  • Duplicate therapy allowed
  • Bad pricing procedures for “compounded” prescriptions
  • Bad pricing procedures with paper submitted claims
  • Inaccurate pricing when the claim is Prior Authorized
  • Inaccurate pricing applied for U&C claims
  • Not limiting the metric quantity and/or days supply to the plan design limits
  • Missing the limitations expected in plan design edits of Step Therapy and Quantity Limits
  • Allowing claim charges when the member is ineligible on the date of service

SCS can apply the base starting data of the standard sources: First DataBank and Medispan. Edit errors on this list of potential problems are impossible to detect without applying software that is designed to mimic the correct adjudication of 100% of your claims.

Audit Gives Knowledge:

A major result of a pharmacy audit is the increased knowledge you and your team will gain from the process. With direct reporting of audit discrepancies and PBM processing procedures, our clients relate that they have a much better understanding of the PBM industry after the audit. With better knowledge you can build a better pharmacy benefit and better understand the pharmacy contract.


111 Center Street     |     Little Rock, Arkansas 72201     |     Ph: 501.377.2300     |     Tf: 800.643.9691