Part D Plan Audit Services


If you’re a Part D Plan (PDP / MA-PD) that relies on PBM relationships to support claim processing and retail network management, you face multiple oversight and administration challenges. That’s why Caribou offers a host of services to assist you with these responsibilities, including:

  • Review of CMS reporting, including Prescription Drug Event (PDE) data sets against paid claims utilization to verify reporting accurately reflects client drug spend, with special attention to how the PBM handles non-Part D claims and reversals.
  • Formulary compliance, including drug tier, exclusions / non formulary and prior authorized products, gender / age restrictions, clinical program edits (quantity limits and step drug programs), and timeliness of processing updates in your PBM’s systems.
  • Benefit administration review for compliance with CMS bid submission as well as plan sponsor limits, including member cost-share review, Wrap Plan coverage and copays, LICS copays, and TrOOP limits.
  • Eligibility Audits, including LICS level validation.
  • Review of how the Part D plan administrator handles pass through of direct and low income cost share subsidies, low income premium subsidies, manufacturer gap discounts and reinsurance credits.
  • Manufacturer rebate audits, including review of Direct and Indirect Remuneration (DIR) as reported to CMS.
  • Validation of processor corrective actions in response to CMS PDE audit findings.


  • Caribou’s experience with eligibility and pharmacy claims data sets prove invaluable in diagnosing processing or set up issues and communicating corrective actions.
  • Caribou’s highly evolved project management methodology and best-in-class technology support accurate and timely reporting in a key compliance area.
  • Caribou’s reputation for quality and professionalism in the industry translates into better service by leveraging our solid working relationships and knowledge of claim processing platforms for all major PBMs and Rx claim processors in the U.S.

For more information about how we can help your organization,