A nationally recognized employer group covering 6,000 lives with multiple plan designs, retained PBIRx for Consulting and Auditing services.
PBIRx renegotiated the current PBM contract several months before the actual renewal date to take advantage of improved terms including rebate and discount pricing. On our first annual audit, the dedicated AuditRx team identified and audited all contractual terms including claims, rebates, plan design, and performance guarantees.
PBIRx’s AuditRx team uncovered the following items:
- Client requested flat dollar Specialty copays. AuditRx identified copays that were set up as a percentage of drug cost. PBM corrected the error, reimbursed member overpayments, and remitted $10,000 to client for missed plan setup guarantee.
- An expensive weight loss medication was set up as a covered drug when in fact it should have been excluded by the PBM. AuditRx recovery from PBM was $25,307.
- Maximum Allowable Benefit on Infertility medications was never implemented. AuditRx recovery from PBM was $154,749.
- PBM identified single source generics differently from contract terms resulting in a larger variance in the number of specialty drugs in their reconciliation calculations. AuditRx recovery from PBM was $320,656.
- PBIRx reviewed and audited all contractual Performance Guarantees. It was determined that the PBM was not meeting the guaranteed metrics. AuditRx recovery from PBM was $100,000.