Verify pharmacy benefit logic
at scale.
Formularies, rebates, and accumulators are complex and constantly changing. We translate that logic into an executable model and verify that every claim follows the rules as written.
PBM logic is hard to verify.
The risk isn't bad intent. It's invisible logic drift — and by the time it surfaces, you've already paid.
Formulary logic drifts
Tier assignments, step therapy rules, and exclusions change — but systems don't always sync.
Rebate calculations are opaque
Complex formulae with thresholds, exclusions, and lookbacks. Hard to verify even with data.
Errors compound silently
A single misconfigured rule affects thousands of claims before anyone notices.
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.
Contract logic violations aren't in any tool's scope
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.
Formulary logic becomes executable
Tier assignments, step therapy rules, exclusions — all machine-verifiable.
Claims map automatically
NDCs, days supply, member status, pricing — aligned with your rules.
Every claim gets verified
Violations, contradictions, and edge cases surface automatically.
Every layer of PBM logic.
Each verification answers a specific question about whether the claim followed the rules as contracted.
YesTier 32/2 tried30 ≤ 30The kind of issues verification catches.
These scenarios represent common patterns that surface when pharmacy benefit logic is verified against actual claims.
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.
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.
From reactive to proactive.
Instead of waiting for disputes to reveal issues, verification surfaces them while there's still time to act.
Issues found during external audits — after payments settled
Disputes escalate before root cause is understood
Plan sponsors ask questions you can't fully answer
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
Reduce audit exposure, increase sponsor trust
Verification creates a defensible record of rule execution.
Start with one slice of logic.
Most PBM engagements begin with a narrow scope:
No system replacement. No workflow disruption.