PBM Audit for Self-Funded Employers
Independent, fee-only auditors expose the spread pricing, retained rebates, and undisclosed fees hidden in your pharmacy benefit contract, with no ties to any PBM.
Where PBM money hides
PBMs often charge the plan more than they reimburse the pharmacy, keeping the difference as spread. This markup is buried in claim-level detail and never disclosed as a line item. On a $5 million claims portfolio, spread alone can move $250,000 a year from the employer to the PBM.
Manufacturers pay rebates to PBMs for preferred formulary placement, but contracts frequently let the PBM retain most or all of those dollars. At the same time, formularies can be steered toward high-margin drugs even when lower-cost equivalents are available, shifting costs to the plan and members.
Administrative fees, DIR fees, and specialty pharmacy markups are often folded into the net price rather than listed separately. Contracts may define fees broadly or cap audit rights, making it hard for self-funded employers to see what they are actually paying for high-cost specialty medications.
What a PBM Audit Recovers
15% to 30%
pharmacy administration savings
$250K
annual spread on a $5M claims portfolio
70%
of costs from 10% of members
How we audit your PBM
Reprice claims to contract
Through our Deerhold partnership, we ingest your PBM claims and machine-readable files, then reprice each line against contract definitions, MAC lists, and dispensing fees.
Rebate and spread reconciliation
We reconcile manufacturer rebates, administrative fees, and pharmacy reimbursements back to your contract to identify retained spread, missing rebates, and undisclosed DIR.
Formulary and contract review
We review formulary placement, prior-authorization rules, and every contract clause, including definitions of generic, rebate carve-outs, and audit-right limits that hide costs.
PBM contract language hides the overcharges
Most PBM overcharges are not accidental. They are permitted by contract language that defines "generic" loosely, allows the PBM to retain spread, carves out rebates the plan never sees, and limits audit rights to narrow windows or specific data sets. We review ASO, TPA, and PBM contracts clause by clause to expose those provisions before they cost you another year of hidden fees.
Download the PBM Contract Red-Flags Checklist
Discover the 10 contract clauses costing employers millions.
Frequently Asked
Ready to see what your PBM is actually costing you?
No obligations. No conflicts of interest. Just an honest look at your data.
Schedule a Free ConsultationOr call (813) 962-7436