PBM Use Case
Verify Pharmacy Benefit & Rebate Logic at Scale
Pharmacy benefit rules and rebate contracts are complex, interdependent, and constantly changing. This platform translates that logic into an executable model and verifies that claims and rebates follow the rules as written.
Claims Adjudicated
All systems reporting normal
2.4M
Claims/mo
99.2%
Processed
0
Errors
Hidden until disputed or audited
The Problem
PBM Logic Is Hard to Verify
Pharmacy benefits involve layered rules — plans, formularies, networks, rebates. Each layer interacts. Errors hide in the gaps.
Formulary logic drifts from contracts
Tier assignments, step therapy rules, and exclusions change — but downstream systems don't always sync.
Rebate calculations are opaque
Complex formulae with thresholds, exclusions, and lookbacks. Hard to verify even with source data.
Errors compound silently
A single misconfigured rule affects thousands of claims before anyone notices.
Where Logic Errors Hide
One misconfigured rule → thousands of incorrect claims
The risk isn't bad intent. It's invisible logic drift — and by the time it surfaces, you've already paid.
The Gap
Why PBM Errors Persist
Every PBM has tools for managing pharmacy benefits. But they each check something different — and none of them verify whether the claim actually followed your contracted logic.
Rule engines encode your intent
Audits sample a small %
Analytics flag outliers
But contract logic violations? They slip through every layer.
Claims flow
Logic errors
pass through undetected
Contract logic violations aren't in any tool's scope
Your PBM Logic
Formulary
Accumulators
Rebates
Verification Engine
Every claim × Every rule × Every edge case
What Surfaces
How It Works
From Contracts to Verified Claims
We add a verification layer above your PBM systems — without replacing them. Your pharmacy benefit logic becomes an executable specification.
Your rules become executable
Formularies, tiering, accumulators, rebate clauses — all machine-verifiable.
Claims map to logic automatically
NDCs, days supply, member status, pricing — aligned with your rules.
Every claim gets verified
Violations, contradictions, and edge cases surface automatically.
What We Verify
Every Layer of PBM Logic
Each verification answers a specific question about whether the claim followed the rules as contracted — not just whether it "looks right."
Formulary & Tier Logic
Accumulator Behavior
Channel & Network Rules
Rebate Eligibility
Overrides & Exceptions
Sample Verification Output
Claim
#PBM-2024-847291
Member
Plan A / Tier 2
Issue Detected
Claim qualifies for rebate under Exhibit B, §4.2(b) but was not flagged in rebate file. Est. impact: $47.20
This runs on
every claim, automatically
Illustrative Examples
The Kind of Issues Verification Catches
These scenarios represent common patterns that surface when pharmacy benefit logic is verified against actual claims.
Tier Assignment
Specialty drug on wrong tier after formulary update
A January formulary change moved 12 NDCs to Tier 4. The claims system was updated, but the accumulator logic still references Tier 3 copay amounts for these drugs.
What Verification Surfaces
Root cause: Formulary update didn't propagate to accumulator tier mapping table.
These examples are illustrative. Actual findings depend on your specific logic and data.
The Outcome
From Reactive to Proactive
Instead of waiting for disputes to reveal issues, verification surfaces them while there's still time to act.
Without Verification
Issues found during external audits — after payments settled
Disputes escalate before root cause is understood
Plan sponsors ask questions you can't fully answer
With Verification
Issues caught before they scale across claims
Root cause traced to the exact rule that failed
Confidence to show sponsors exactly how logic is applied