Pharmacy Audits

For employers who self-insure their employees’ pharmacy benefits, Healthcare Horizons offers comprehensive pharmacy audits to verify accuracy in payment of claims, identify and recover overpayments, and discover root-cause errors that may be corrected for long-term savings.


After obtaining the claims dataset from the client, the data is thoroughly tested and reviewed for payment and/or documentation errors, taking into account any/all of the following:

  • Eligibility
  • Patient responsibility (deductible, copays, coinsurance)
  • Day’s supply
  • Formulary administration
  • Fraud and abuse
  • MAC application
  • Specialty pricing
  • Covered drugs
  • Duplicate claims

In addition to gathering and reviewing the initial data, pharmacy audits may also include field audits to take place at selected outlier pharmacies. Any deficiencies found may also be shared with the pharmacy benefits manager (PBM), whose responses are included in the final audit report. During the process, not only do we identify and flag specific overpayments, but we also look for system-wide issues that can be corrected to make payment more accurate in the future.

Once the audit is complete, Healthcare Horizons will deliver to the client a final audit report detailing all factors that were tested and our overall findings, an account of erroneous claims, and any root-cause issues that were identified during the course of the audit.

Conducting periodic pharmacy audits can add up to significant savings in the long run for self-insured employers. Healthcare Horizons goes to great lengths to make sure our clients are paying as accurately as possible and to recover the maximum possible amount of any overpayments. To learn more about our pharmacy audit services, contact us here.