Pharmacy Benefit Audits: Enhancing Plan Oversight

Pharmacy benefit audits are essential to maintaining the integrity and value of benefit plans. They play a crucial role in holding pharmacy benefit managers (PBMs) accountable to their contractual commitments. In this blog, we will explore three types of pharmacy benefit audits National CooperativeRx conducts to ensure our members receive the full value of their pharmacy benefit plans at no additional cost to them.

1. Claims Audit

National CooperativeRx enlists an independent third-party auditor to review 100% of our members’ claims during the audit period, examining contracted pricing, discounts, dispensing fees, and minimum rebate guarantees. This process involves a thorough comparison of claims data against pricing guarantees and payment reports. Any discrepancies are submitted to CVS Caremark for review, with written responses requested for each claim in question. Once responses are received and the audit is complete, the auditor delivers a comprehensive report to National CooperativeRx. After our internal review and quality check, 100% of recoveries are returned to our members. These audits are conducted at no cost to our members.

In addition to our annual claims audits, we conduct periodic internal reviews of new contract pricing and annual market checks to proactively maximize the value and performance of our members’ pharmacy benefit plans. These reviews are provided at no cost to our members.

2. Rebate Audit

National CooperativeRx also enlists an independent third-party auditor for our periodic full rebate audit. This audit ensures CVS Caremark has accurately invoiced drug manufacturers and properly allocated rebates based on each member’s claims utilization and our contract terms. The auditor receives a rebate billing summary report from CVS Caremark, along with claims files for the audit period. They then review the manufacturer agreements to calculate the expected rebates, price protections, administrative fees, and rebate credits. The auditor compares their findings to the summary provided by CVS Caremark to identify any discrepancies. Their final audit report, with redacted rebate terms and their findings, is then submitted to National CooperativeRx for review. Similar to our claims audits, 100% of all verified rebate recoveries are returned to our members. All rebates received exceeding guarantees are passed back to our members in the form of true-up on an annual basis.

National CooperativeRx also internally audits rebate payments as we receive them from CVS Caremark to ensure guarantees are being met and match the terms of our contract. Unlike those who charge for audits or keep a portion of recovered funds, both external and internal rebate audit processes are provided at no additional cost to our members.

3. Plan Design Audit

During implementation, National CooperativeRx conducts a general plan design audit internally to verify plan setup is accurate from the start. Our goal is to ensure the member group’s intentions are accurately reflected in the paperwork provided to CVS Caremark and properly transferred into their coding system. We run test claims using sample profiles to confirm the plan is configured correctly. After implementation, we continue to monitor the member group’s claims for a period of time to confirm that plan design elements are applied accurately. These reviews are conducted at no cost to our members.

National CooperativeRx’s Commitment

At National CooperativeRx, we manage our members’ pharmacy benefit plans with integrity, accountability, and a strong sense of stewardship. By upholding this high standard of vigilance and oversight, our members can trust that they will receive the full value of their pharmacy benefit plans with us.

If you have questions about our audit processes or how we support your pharmacy benefit plan, please reach out to your National CooperativeRx Account Representative.