What is pharmacy payment integrity? A beginner’s guide for employers and health plans

Pharmacy spend is rising fast, driven by GLP-1 demand, specialty therapies, and complex benefit designs. That’s pushed many plans and employers to ask a simple question: how do we contain our pharmacy spend? 

Pharmacy payment integrity is the discipline of ensuring every claim is paid accurately, according to pricing rules, clinical edits, and benefit logic — not just according to what’s written in a PBM contract. It pairs continuous monitoring with targeted audits so you prevent overspend in real time, not months later. 

Why pharmacy payment integrity is different from traditional PBM audits 

Audits look back. They’re episodic, sample-based, and great for vendor alignment and recoveries. Payment integrity looks forward and sideways reviewing 100% of claims continuously to catch systemic issues like misapplied lesser of logic (LoL), missed coordination of benefits (COB), inconsistent prior authorizations (PA), duplicate therapy, and benchmark mispricing (e.g., NADAC not considered). 

Think of it this way: 

• Contract variance checks if your PBM followed the contract. 

• Systemic integrity checks whether each claim was actually processed correctly. 

You need both, but integrity is where most day-to-day savings live. 

Common leakage scenarios (with quick examples) 

• Lesser of logic blind spots: Contract compares U&C/AWP/MAC, but NADAC is lower and not applied — claim overpays. 

• PA inconsistency: Diabetes-only GLP-1 coverage is correct on paper, yet some claims bypass PA — inappropriate payments slip through. 

• COB misses: Claim carries OCC 02 (secondary), but prior paid amount from the primary isn’t reported — plan pays too much. 

• Duplicate therapy / early refills: Overlapping prescriptions or refills before threshold — avoidable spend and safety concerns. 

What pharmacy payment integrity is (and is not) 

It is: 

• Always-on oversight that reviews every claim. 

• A complement to PBM relationships focused on alignment — shared fixes, fewer surprises. 

• A source of cost avoidance that protects members from churn and reprocessing. 

It is not:

• A replacement for audits: those still matter for vendor alignment and compliance checks. 

• Just “contract policing”: it validates the real-world logic behind every paid claim. 

• Only about recoveries: prevented dollars are often the bigger win. 

The metrics that matter 

• Clean claim rate: % of claims that pass all integrity checks without a flag. As issues are fixed, this rate should climb. 

• Detection-to-resolution time: How quickly flags lead to durable fixes (logic, configuration, or policy). 

• Cost avoidance vs. recoveries: Show both — avoidance signals proactive control; recoveries prove retrospective rigor. 

• Conversion rate of flagged claims: % of identified opportunities that result in a confirmed correction or recovery. 

The business case 

• Budget protection: Avoid leakage before dollars leave the door. 

• Operational focus: Direct internal teams to true root-cause fixes, not spreadsheet hunts. 

• Better vendor alignment: Evidence-based conversations that produce faster, lasting corrections. 

• Member experience: Fewer reprocessed claims, fewer surprises at the counter. 

Wrap-up 

Pharmacy payment integrity turns pharmacy oversight from a rearview activity into a daily habit. It elevates your conversations beyond contract variance to how claims actually run — every day, for every member. Get the foundation right, measure what matters, and keep your PBM aligned on durable fixes. Your clean claim rate, and your spend, will show the difference.