The Pharmacy Benefit Audit Playbook
Audits Every Payer Should Be Considering and How PSG Can Help Pharmacy benefit audits should go beyond checking a compliance box. When approached strategically,…
Plan Design Audits
SOLUTIONS
Plan Design Audits
Your pharmacy benefit plan is only as effective as how accurately it’s set up and administered. With increasingly complex plan designs, multiple lines of business, frequent benefit changes, and growing regulatory requirements, even small configuration errors can quietly compound into significant cost impacts and member experience issues. Plan design audits verify that your PBM is accurately translating your benefit intent into day-to-day operations, from member cost share and drug exclusions to eligibility windows and accumulator logic, giving you the confidence that your plan is performing exactly as you designed it.
Uncover Hidden Value. Protect Every Dollar
Ensure Contract Compliance
Regular audits verify that your PBM is adhering to agreed-upon terms, from plan design to eligibility accuracy, across complex and nuanced contracts.
Recover Dollars Left on the Table
Plan design errors and eligibility mismatches can quietly drive overpayments and member cost share discrepancies. PSG audits consistently deliver recoveries where issues are identified.
Strengthen Fiduciary Responsibility
Plan design and eligibility audits are a key component of demonstrating prudent oversight and protecting plan assets.
Turn Audits Into Strategy
When approached strategically, plan design audits go beyond compliance to confirm that benefit intent translates into day-to-day operations, allowing payers to focus less on operational issues and more on strategy.
PSG’s Plan Design Audits
Benefit Design Audit | Eligibility Audit
Benefit Design Audit
A Benefit Design Audit provides a full assessment of how your PBM is processing claims relative to your contractual requirements and documented benefit designs. This audit delivers reassurance that your pharmacy benefit plans are being accurately adjudicated by holding the PBM accountable for implementation of corrective action plans (CAPs), calculation of financial impacts, and reprocessing of erroneous claims.
The review validates the accuracy of plan design parameters including exclusions, limits, DAW rules, benefit accumulators, out-of-pocket maximums, and member cost share. Even minor discrepancies in plan design setup can lead to significant cost impacts and member experience issues, which is why it is important to audit not only copays and coinsurance, but also the setup and adjudication of elements such as custom drug lists, drug exclusions, days’ supply limits, and refill too soon rules.
Common Triggers for Conducting This Audit:
- Multiple complex plan designs, significant changes to existing plan designs, or implementation of new plan designs
- Adding a new line of business or transitioning to a new PBM
- Formulary changes, regulatory updates, or industry shifts
- Drastic changes in per member per month (PMPM) prescription drug claims trends
- Historical experience of errors by the PBM
- Known adjudication issues causing member dissatisfaction
Eligibility Audit
An Eligibility Audit ensures that paid claim service dates fall within eligible time periods for both members and dependents. Eligibility is the front door to pharmacy benefits. If the right eligibility is not accurate at the moment a claim is processed, every downstream decision, including pricing, accumulators, and benefit design application, is at risk.
This audit validates that claims were adjudicated only for members with active coverage during the applicable service period, catching errors caused by retroactive terminations, delayed enrollment updates, or misaligned coverage effective dates. Incorrect eligibility can result in rejected claims for covered members, paid claims for ineligible individuals, misrouted benefit logic, and inaccurate financial reporting.
An eligibility audit provides the oversight needed to confirm that enrollment data flowing between your organization and the PBM is accurate and current, reducing reconciliation complexity and protecting both plan assets and the member experience.
Common Triggers for Conducting This Audit:
- Transition to a new PBM or change in adjudication platform
- Known issues with retroactive eligibility additions or terminations
- Discrepancies between enrollment system records and PBM eligibility files
- Member complaints about coverage denials tied to eligibility status
- Changes in eligibility file transmission processes (e.g., batch to API migration)
- Adding a new line of business or integrating medical and pharmacy eligibility feeds
Why choose PSG?
Independence You Can Trust
Our audit findings are free from PBM affiliations or industry bias. When we evaluate your plan design and eligibility accuracy, the results are fact based, not influenced by a vendor relationship. That objectivity is what gives our audit conclusions credibility and weight at the negotiating table.
Unmatched Audit Expertise
Our auditors combine pharmacy benefit experience with technical expertise in a way few organizations can match. This dual fluency means we don’t just run the numbers, we understand the clinical and contractual context behind them, allowing us to catch discrepancies others overlook and translate complex findings into clear, actionable insights. Our team brings specific plan design and benefit validation experience, having worked with PBMs to correct identified errors and to support resolution of any contractual shortfalls.
Breadth Across Every Market and Size
Our audit capabilities span every major market segment (Commercial, Exchange, Medicare, Medicaid, and beyond). Whether you cover 500 lives or 5 million, we have the experience and methodology to scale accordingly. This breadth means we bring cross-market perspective to every engagement, identifying patterns and discrepancies informed by what we see across the full landscape of pharmacy benefit programs.
Flexible, Tailored Approach
No two pharmacy programs are alike, and neither are our audits. Full-scope and a la carte audit options give you the flexibility to target specific areas of concern, whether that’s a single benefit validation review, a focused eligibility check, or a comprehensive assessment across multiple plan designs and eligibility processing validation to ensure accurate claim adjudication.