Plan Benefit Audits

Plan Benefit Audits test for accuracy in programming of member contribution and clinical plan design attributes. Caribou’s standard practice is to review 100% of all paid claims. Options exist to test member out-of-pocket programming with stratified random samples. However, in Caribou’s experience, the thoroughness of the 100% review cannot be easily or cost effectively replicated when it comes to reviewing drug coverage rules using a sample technique.

The plan design validation process is accomplished using CRx, Caribou’s proprietary pharmacy claims audit tool. Caribou analysts load your plan design attributes into the CRx rules engine and then accurately and efficiently re-adjudicate the full claim file. All claims failing any plan design attribute are reported by the system for analyst review and trend analysis. The PBM is then provided with copies of all claims in question, along with a representative sample selected for their research and rebuttal.

Plan Benefit Audit Options

Member Contribution

  • Copay
  • Maintenance Choice Copay
  • Exception Copays
  • Dispensing Limits
  • Copay MS Brand Drug Type
  • Mandatory / Incentivized Mail Order
  • Deductible
  • Maximum Out-of-Pocket (MOOP)
  • Maximum Allowable Benefit
  • Diabetic Copay Rule

Clinical Edits

  • Exclusions
  • Prior Authorization
  • Quantity Limits
  • Step Therapy


  • Our CRx system reviews 100% of the paid claims data during the benefit audit.
  • CRx is highly configurable and can be customized with audit rules to your specifications.
  • CRx supports a significantly “deeper dive” when reviewing clinical program rules to identify claim payment errors — with the ability to load thousands of drug products.
  • Caribou maintains a database of drug classification and clinical attributes to validate the accuracy and completeness of PBM clinical drug lists
  • Our audit staff can recognize error trends and PBM processing weaknesses or gaps against industry standards.
  • Our knowledge of PBM standards allows us to identify areas where claim processing is set up based on PBM defaults instead of per client intent, resulting in inconsistencies in claim payments across plans for the same client.

For more information about how we can help your organization,