PBM Rebate Audits and Consulting Services

Pharmacy now accounts for approximately 27 percent* of the total benefits spend and is expected to continue growing. As stewards of employee health plans, plan sponsors have a fiduciary responsibility to carefully manage pharmacy benefit costs while delivering the coverage employees need. 

PBM rebate audits play a significant role in reducing those costs, especially for brand-name and specialty drugs. Pharmaceutical manufacturers pay rebates to employers, insurers, or pharmacy benefit managers (PBMs) in exchange for including their brand-name drugs on the formularies of these entities.Clinical pharmacists represent 62 percent of our PBM rebate consulting team, bringing deep expertise working with PBMs. They design plans that ensure transparency, so plan sponsors can clearly assess rebate program ROI and optimize overall value.

*According to the Business Group on Health 2025 survey.

Uncover Missed Savings With Pharmacy Benefit Rebate Audits

PBM rebate audits reveal whether you’re receiving the full value your contract promises – or just the portion your PBM feels like passing through. Actual rebate amounts vary depending on the model used, specifically whether it is traditional or pass-through. 

In a traditional model, the PBM keeps a portion of the rebates; in a pass-through model, 100 percent of rebates are returned to the plan sponsor.

Our team conducts targeted pharmacy benefit claims audits to determine how much rebate revenue your pharmacy benefit manager is retaining. We identify missed savings and verify that rebate guarantees are being met. By comparing PBM rebate contracts with actual claims data, we identify discrepancies and ensure that all eligible rebates are submitted accurately.

Contract Review: Are You Receiving What Was Promised?

Our PBM rebate audits include a detailed review of the contract to verify that your pharmacy benefit manager is delivering on the negotiated rebate terms. We assess rebate guarantees, payment timelines, and pass-through provisions to ensure full compliance. 

If there’s a gap between what was promised and what was paid, we flag it and help you recover it.

Maximize Rebate Value With Smarter Plan Design

Innovative Rx Strategies brings strategic insight, industry expertise, and contract analysis to refine benefit designs and increase rebate revenue. Our pharmacists and PBM rebate consulting team help you get more value from every dollar spent by recommending plan design enhancements, including: 

• Formulary Management: Our PBM formulary consultants evaluate your current formulary to identify opportunities for more substantial rebate ROI. That may include replacing low-value drugs, leveraging generics or biosimilars, and lowering copays for preferred brands with substantial rebates, all without disrupting care.
• Prior Authorizations: We strengthen clinical standards to ensure appropriate use of medications, improving outcomes and reducing waste. Unlike superficial “checkbox” approvals, our approach delivers actual value.
• Pharmacy Networks: Savings are achieved by working with pharmacy networks that contract with PBMs to provide medications at negotiated rates.

With these strategies, our PBM rebate audits and consulting services ensure your plan design maximizes rebate potential while controlling costs and protecting member care.

PBM Pricing Optimization: Lower Costs, Better Terms

Our PBM consultants negotiate better pricing and structure contracts to maximize rebate guarantees and ensure the highest levels of transparency.  

Contract Expertise: The contract with your PBM is the most critical aspect of your relationship. We review PBM contracts and incorporate our proprietary standard definitions, terms, and conditions to ensure that rebate terms are clearly defined. 

Our data show that most PBM contracts contain fewer than a third of the definitions, terms, and conditions we require.

Competitive PBM Procurement: Our comprehensive and proven PBM request for proposal (RFP) process leverages our relationships with the 50+ PBMs we have vetted to drive competition, optimize rebate terms, and lower pharmacy costs.

Most contracts do not accurately represent the agreed-upon terms outlined in the RFP.