Pre-Implementation Audits have become increasingly popular with plan sponsors and payers who are implementing new plans or updating benefits under an existing PBM relationship, moving to a new PBM, or for clients concerned with validating PBM platform transitions. These changes include not only commercial plans, but new EGWP plans as well.
Validating benefit set up prior to the “go live” date will help ensure a smooth transition from contracting through implementation. Caribou’s Pre-Implementation Audits will first verify that the PBM vendor has:
- Accurately documented the plan benefits
- Interpreted the benefits according to the client’s intent
In addition, the audit will verify that the PBM has set up the claims adjudication system correctly, focusing on the following areas:
- Member Out-of-Pocket (OOP) for both Retail and Mail
- Generic
- Formulary
- Non Formulary
- Exceptions
- Clinical Program – Drug Coverage
- Exclusions
- Prior Authorization Drugs
- Quantity Limits
- Step Therapies
- Financial Review
The scope of a Pre-implementation Audit can be customized based on the number of plans in scope and the requested number of claims in the test plan. Caribou has experience working with all of the major PBMs and is familiar with each of their testing processes.