Today’s pharmacy benefit landscape can feel like a minefield of complex contracts, performance promises, intricate plan designs, and endless benefit considerations. Employers must trust in their PBMs to deliver on promises. How can plan sponsors be sure they are receiving what is owed? The answer is a comprehensive third-party audit program.
Here are three other questions and answers to accelerate the review of plan performance:
Is it an employer’s responsibility to ensure the PBM adheres to contract terms?
With the complex architecture and high volume of data flowing through PBM systems daily, errors and unexpected financial results can occur. Despite how meticulous a team may be, there are inevitable implementation errors and misunderstandings of client intent. That’s why it’s crucial to ensure a PBM correctly delivers every contractual element of a pharmacy drug plan.
How to ensure a PBM is holding up its end of the contract?
Plans should perform a yearly series of audits to ensure a PBM upholds the contract terms and deliver appropriate financial benefits. By exercising the right to audit PBM claims, plans hold the PBM accountable for the proper plan administration and maximize the PBM contract’s value.
When there is a great contract, why would an audit be necessary?
Pharmacy spend can easily represent 15 to 20 percent of total health expenditure. Any error in implementing plan design or pricing threatens the integrity of drug spend and the value optimization of the PBM contract.
And though pricing errors are the easiest to recognize, discrepancies in plan design implementation can be just as costly—and they may disrupt plan membership. Plan sponsors often invest substantial time and resources in PBM contract negotiation. But don’t stop there. Audit annually to ensure a contract is being honored and implemented as it should.
These questions are the starting point when it comes to audits. Perhaps the most tremendous potential for audit recovery is financial guarantees. I have much more to share about financial guarantees in the PSG Complete Playbook.
Download the playbook and skip to Page 13 to understand the potential financial guarantees hold in 2022.