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PBM Auditing & Consulting

PBM Auditing & Consulting Services

ConsultingEHIM consulting's 360° PBM audit provides complete visibility into all aspects of your pharmacy program. The 360° PBM audit will allow you to rest assured that your PBM is not only processing your claims properly, but also acting in your best interests. We perform reviews at varying degrees, from small market checks to a complete audit, to ensure you receive all the necessary information to recoup your costs. Through the utilization of extensive data analysis and a multitude of experience in the PBM industry, EHIM is able to provide recommendations, including:

Discount Evaluation

The discount evaluation verifies that you are receiving your contracted discounts on each and every prescription claim. All discrepancies are included in the Audit Report.

Plan Compliance

Plan compliance verifies that only appropriate drugs are being covered under the plan and the correct member copays are being applied.

Eligibility Verification

Eligibility verification ensures that only eligible members are receiving benefits through the pharmacy plan.

Clinical Program Compliance

Clinical program compliance verifies that all clinical programs contracted under the plan, such as prior authorizations, step therapy or quantity limitation programs, are being conducted properly and are being invoiced accurately.

Contract Analysis

The final audit report will contain an analysis of your pharmacy contract, including hidden sources of PBM revenue, data sharing provisions, and areas where the PBM's obligations are not aligned with your best interests. The audit will also provide actionable recommendations on how the contract can be strengthened in future negotiations.

Plan Design Review

The plan design review provides recommendations for plan changes to lower costs and improve the overall strength of the program.

Group Health Review

The group health review goes beyond statistics to provide information on the health of the group. We look at top conditions, utilization patterns and projected costs.

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