- 0.5x
- 0.8x
- 1x
- 1.2x
- 1.5x
- 2x
National CooperativeRx recently distributed $22.7 million to members following the completion of our 2023 and 2024 pharmacy benefit claims audits. This significant distribution reflects the growing importance of independent oversight in recovering PBM contract value.
Understanding National CooperativeRx’s Recent Distribution
National CooperativeRx enlists third-party auditors to conduct annual independent audits on behalf of our membership at no additional cost to them. Auditors review 100% of claims across all plans to confirm compliance with our master contract with our PBM vendor. All recoveries are returned to plan sponsors.
Historically, recoveries have been minimal, but as audits have grown more complex, they have led to larger recoveries and longer turnaround times. For 2022, $6.1 million was returned to plan sponsors. Due to delays in securing collections from that audit cycle, the 2023 and 2024 audits were conducted simultaneously, resulting in $7.3 million from 2023 and $15.4 million from 2024 distributed to members in May 2026.
The payment also included Q4 2025 rebates and prior quarter rebate adjustments, if applicable. Adjustments were identified through an extensive review of 2024 rebate activity, along with 2025 activity to date. Adjustments can be positive or negative based on changes in claim counts, claim eligibility, rebate credit language, or payment errors. Actual adjustment amounts were outlined in letters to plan sponsors.
A Note on Rebate Transparency
National CooperativeRx passes through 100% of negotiated rebates to plan sponsors on a quarterly basis. Prior to 2024, rebate adjustments made by our PBM vendor, CVS Caremark, were incorporated into current-quarter guarantees, limiting visibility into prior period adjustments. New tracking methods now isolate and report these adjustments separately, improving transparency. Now that these processes have been clarified, future adjustments will be detailed and applied quarterly.
How Audits Vary Across the Industry
Audits help identify discrepancies, capture missed value, and confirm whether PBM contracts are performing as intended. However, audit methodologies can vary significantly across arrangements, directly impacting the value plan sponsors are able to realize.
Audit rights are not guaranteed in every PBM contract. Some contracts exclude them entirely, others include restrictions on what can be reviewed or who can conduct the audit. Some provide broader flexibility that allows for more meaningful oversight. PBMs may conduct their own audits, which can create a conflict of interest. When permitted, some plans engage an independent auditor.
Some audits are limited to specific time periods while others cover the full contract term or year. Audits may not review every claim and may only be focused on specific contract elements such as pricing, rebate reconciliation, generic dispensing rates, formulary compliance, or specialty drug billing. A narrower audit may identify certain discrepancies but miss others, making depth and breadth critical factors in overall value recovery.
In most cases, plans bear the cost of a PBM audit. Depending on the arrangement, the auditor or PBM may retain a portion of any recoveries identified, and the PBM may also charge audit-related fees.
Audits as a National CooperativeRx Member
National CooperativeRx removes many of the audit barriers plan sponsors commonly face across the industry, including cost, restricted access, and limited audit scope. Annual independent audits are conducted at no additional cost, every claim is reviewed, and all recoveries are returned directly to plan sponsors.
As a member-owned, not-for-profit cooperative, providing independent oversight is a core part of National CooperativeRx’s approach to protecting member value. The recent distributions to plan sponsors demonstrate the impact comprehensive audits and full pass-through of recoveries, rebates, and related adjustments can have in helping ensure PBM contract value is fully realized.
Contact our team to learn more about National CooperativeRx’s approach to independent PBM oversight.
