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PBM Audits:
Crystal Clear Rx has performed PBM audits for large and small companies in a wide range of industries.
The Basic PBM Audit | will help you to know if contractual commitments for pricing and service are being met by your PBM. Crystal Clear Rx has the expertise to obtain and convert data from PBMs into a useable format. We prepare a complete summary report with an accompanying action plan.
The comprehensive Crystal Clear Rx Audit |will include everything in the basic audit, plus a adjudication review and clinical and benefit analysis that includes financial projections and a complete plan of action for the client.
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The PBM contract agreement can be difficult to understand, changes with Brand and Generic drugs can impact your programs performance, drug recall or changes within the industry, and with thousands of transactions occurring every month, it becomes overwhelming.
Crystal Clear Rx works for you. During our PBM audits we search for discrepancies that impact your bottom line. Our audits include:
- CCRx search for inaccurate application of MAC Pricing.
- CCRx identifies errors with the wrong AWP dollar amount for calculation of cost.
- CCRx will uncover inaccurate assignment of Brand / Generic label (missing deserved contract discount).
- CCRx will spot missing generic substitution copay penalty or disregard of Dispense As Written rule as a substitutable brand and therefore not applying the penalty.
- CCRx discovers improper use of pricing for contracted discounts.
- CCRx will investigate allowed "excluded" drugs to process without a proper Prior Authorization.
- CCRx will explore missing contracted "guarantees" on discounts and dispensing fees and get you paid.
- CCRx will detect any duplicate therapy allowed.
- CCRX will isolate bad pricing procedures for "compounded" prescriptions and with paper submitted claims.
- CCRx will find inaccurate pricing when the claim is Prior Authorized
- CCRx will uncover inaccurate pricing applied for U&C claims
- CCRx will communicate industry trends and how they impact you.
- CCRx will review metric quantity and/or days supply to the plan design limits to ensure they are within contractual agreement.
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