prescription benefit audit checklist

How to Audit Your Prescription Benefits: Essential Year-End Checklist 2025

November 11, 2025

Key Takeaways

Review your formulary tiers and understand copays vs. coinsurance to identify high-cost medications for optimization
Calculate total 2025 prescription spending using receipts and insurance statements to spot savings opportunities
Schedule final refills and use remaining FSA funds before year-end deadlines to avoid forfeiting benefits
Set up medication reminders and explore discount programs like Inside Rx for up to 80% savings in 2026
Discuss cost-effective alternatives with your provider using real-time benefit tools to reduce out-of-pocket expenses

A prescription medication pill bottle, Rx Form, and blister pack arrangement

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Health insurance plans and prescription benefits reset on January 1, creating a critical window for benefit optimization before 2025 ends. Most Medicare and health insurance benefits expire on December 31, meaning unused benefits represent "free care left on the table”. Flexible spending accounts (FSAs) typically don't roll over to the next year, resulting in forfeited unused funds. Health plans reset their deductibles on January 1, requiring full out-of-pocket payments until your 2026 deductible is satisfied.

Preventive wellness appointments receive full coverage from most health insurance providers, while contribution and benefit limits have increased for 2025. These factors create optimal conditions for prescription coverage review. This step-by-step process will help you audit your prescription benefits and capture valuable coverage before the December 31 deadline.

Understand Your Prescription Benefits Plan

Prescription benefits review forms a critical component of your year-end benefits audit. Plan coverage details can generate annual savings of hundreds or thousands of dollars when properly understood.

Know what your plan covers and excludes

Prescription drug plans maintain a "formulary", the official list of covered medications. This list encompasses brand-name and generic drugs, plus biological products and biosimilars. Plan formularies use tier structures, with each tier establishing distinct out-of-pocket costs:

Tier 1: Lowest copayment, typically generic drugs
Tier 2: Medium copayment, preferred brand-name drugs
Tier 3: Higher copayment, non-preferred brand-name drugs
Specialty tier: Highest copayment, very high-cost medications

All Medicare plans must provide coverage for drugs in six protected classes: cancer drugs, HIV/AIDS treatments, antidepressants, antipsychotics, anticonvulsants, and immunosuppressants for organ transplants.

Formulary exceptions remain available when your medication lacks coverage. Your doctor must submit a statement documenting the medical necessity of the specific drug. This exception process can secure coverage for medications not typically included in your plan.

Identify your copay, coinsurance, and deductible

Cost-sharing terms require precise understanding for accurate budgeting:

Copay: Fixed fee paid at each doctor visit or prescription fill. Standard amounts include $20 per doctor visit or $10-$20 for preferred medications.
Deductible: Amount paid before insurance cost-sharing begins. The maximum Part D deductible for 2026 reaches $615, increased from $590 in 2025. Plans may offer lower deductibles or eliminate them entirely.
Coinsurance: Percentage paid after meeting your deductible. With 20% coinsurance on a $600 medication, you pay $120 while your plan covers the remaining $480.

Scenario example: $400 deductible for Tier 3-5 drugs with 20% coinsurance for Tier 3 medications. A $600 Tier 3 drug requires the full $400 deductible payment first. The remaining $200 incurs 20% coinsurance ($40), creating a total payment of $440.

Check for any plan changes in 2026

Annual prescription plan modifications affect medication costs. Key 2026 changes include:

Out-of-pocket maximum for prescription drugs increases from $2,000 in 2025 to $2,100 in 2026
Maximum Part D deductible rises to $615 in 2026
Plans are transitioning from copays to coinsurance for specific drugs
2025 Medicare Prescription Payment Plan participants face automatic reenrollment unless they opt out or change plans

CMS continues prescription drug cost control efforts. After negotiations, the average standalone Part D plan total premium projects a decrease from $38.31 in 2025 to $34.50 in 2026.

Medicare Plan Finder updates with 2026 plan information beginning October 1, 2025. An AI-powered prescription cost estimator will subsequently enable price comparisons across local pharmacies.

Plans offering insufficient value may warrant consideration of Inside Rx, which potentially saves up to 80% on medications at 60,000 participating pharmacies nationwide.

Audit Your Prescription Usage in 2025

Prescription usage analysis reveals optimization opportunities before year-end deadlines. This examination of your actual medication consumption throughout 2025 identifies areas for cost reduction and benefit maximization.

List all medications you've filled this year

Medication inventory compilation provides insights into prescription usage patterns. Documentation requires:

Gathering all prescription bottles and packages
Accessing pharmacy account online for digital history
Reviewing insurance claims statements or explanation of benefits
Checking patient portals from healthcare providers

Document each medication name, dosage, prescribing physician, fill dates, and costs paid. This information establishes your audit foundation and reveals medication usage patterns.

Identify unused or duplicate prescriptions

Medication duplication occurs when multiple medications from the same therapeutic class are prescribed during overlapping periods. Research shows 13.37% of prescriptions have potential duplication issues. These duplications create multiple problems:

Health risks: Duplication can cause adverse drug reactions
Financial waste: Increases medical expenditures unnecessarily
Environmental impact: Millions of prescriptions go unused annually, with over 3 tons of prescribed medications wasted in Taiwan alone

Audit your medications for:

Different brand names for the same active ingredient
Similar medications prescribed by different specialists
Prescriptions that were changed but never discontinued
Medications you've stopped taking but continue to refill

These issues require discussion with your healthcare provider for consolidation options. Partially used or expired medications should never be flushed, locate a medication take-back program for proper disposal.

Evaluate adherence and missed refills

Medication adherence, taking prescriptions exactly as directed, affects health outcomes significantly. Nearly half of all patients prescribed chronic medications don't adhere to their regimen. This non-adherence costs the US healthcare system between $100 and $290 billion annually.

The "proportion of days covered" (PDC) measures adherence using standard methodology. Patients with PDC ≤80% or with more than one refill gap (defined as 7+ days without medication) are considered non-adherent. Common reasons for missed doses include:

Forgetting to take medication
Running out before refilling
Being away from home without medication
Trying to save money

90-day medication refills significantly increase PDC rates. Pharmacist-delivered telehealth interventions paired with 90-day fills demonstrate a 9% improvement in PDC versus a 3% decline in those who didn't convert.

Cost barriers to adherence can be addressed through Inside Rx, which may save up to 80% on prescription medications at 60,000 participating pharmacies nationwide.

Evaluate Costs and Out-of-Pocket Spending

Prescription cost analysis forms a critical financial component of your year-end benefits review. Understanding your 2025 spending patterns enables informed decisions for the upcoming year.

Calculate total prescription spending in 2025

Consumer out-of-pocket prescription expenses totaled $58.20 billion in 2023—including cash-pay prescriptions, copayments, and coinsurance—representing 13% of net outpatient prescription drug expenditures. Tracking your personal contribution to this spending provides essential data for your benefit audit.

Calculate your total prescription spending through these steps:

Collect all prescription receipts and statements from January through December 2025
Sum copayments, coinsurance amounts, and full-price payments
Include medications purchased with cash or discount cards
Document reimbursements received through insurance claims
Mark when you reached your deductible and out-of-pocket maximum

Prescription costs fluctuate throughout the year. Early 2025 payments likely covered full medication costs until your deductible was met. After that threshold, you paid either flat copays or percentage-based coinsurance until reaching your out-of-pocket maximum.

The Inflation Reduction Act has altered the cost landscape for Medicare beneficiaries. Medicare Part D redesign implementation began phasing in during 2024, eliminating patient cost-sharing in the catastrophic phase. The IRA will reduce out-of-pocket spending growth from 2.5% in 2024 to 0.6% for 2025.

Use pharmacy receipts or insurance statements

Accurate record collection supports effective benefit auditing. Insurance provider online portals typically offer downloadable statements containing:

Year-to-date spending: Total amounts paid toward your deductible
Claim history: Detailed breakdown of each prescription filled
Explanation of benefits (EOB): Insurance payments versus your financial responsibility

Your pharmacy can generate an annual prescription history report detailing every medication filled, amounts paid, and service dates. This record becomes particularly valuable when using multiple pharmacies.

Organizing these documents chronologically creates a clear financial timeline. This organization identifies when you reached key insurance plan thresholds, including your deductible or out-of-pocket maximum.

Look for high-cost medications to optimize

Kaiser Family Foundation survey data shows three in ten people struggle to afford prescription drugs, rising to nearly four in ten among households earning below $40,000. Your highest-cost medications present the greatest optimization opportunities.

Flag medications where you paid:

More than $100 per fill
Coinsurance rather than copayments (typically 25-33% of drug cost)
Full price due to plan non-coverage

Specialty tier drugs (costing more than $950 monthly) carry median coinsurance rates of 25% for PDP enrollees and 30% for MA-PD enrollees. Many Part D enrollees face coinsurance rather than copayments for preferred and non-preferred brands, creating less predictable out-of-pocket costs.

After identifying high-cost medications, explore options like Inside Rx, which may provide up to 80% savings on prescription medications at 60,000 pharmacies nationwide. Healthcare provider discussions about therapeutic alternatives could yield substantial savings—clinics using real-time benefit tools achieved 11.2% lower out-of-pocket costs when lower-cost alternatives were available.

Approximately 70% of primary care patients have multiple chronic conditions and take four or more medications regularly. Careful cost analysis and proactive management through your prescription benefit audit can prevent unnecessary overpayment.

Take Action Before Year-End Deadlines

December approaches with time-sensitive requirements for maximizing your 2025 benefits. Specific actions must be completed before year-end to capture full value from your prescription coverage.

Schedule final refills before December 31

Insurance plans typically allow refills when you've used 75-80% of your current supply. Controlled substances follow stricter protocols—often requiring 28 days between refills. Check remaining refills and contact your pharmacy promptly to prevent insurance coverage gaps in early 2026.

Medications costly under your current plan may benefit from Inside Rx consideration. This prescription savings option could help you save up to 80% on medications at 60,000 pharmacies nationwide, particularly valuable when facing a new deductible in January.

Use remaining FSA funds on eligible items

Americans lose approximately $1 billion in unused medical FSA funds annually. FSA accounts following the use-it-or-lose-it rule provide until December 31 for spending these pre-tax funds.

FSA-eligible items extend beyond prescriptions:

Over-the-counter medications like allergy treatments, pain relievers, and cold medicines
First-aid kits, sunscreen (SPF 30+), and medical supplies
Menstrual products including period-proof underwear

The 2025 Health Care FSA contribution limit is $3,400, with the option to carry over up to $680 to 2026 if your plan permits. Verify if your plan offers a grace period or rollover option before spending deadlines.

Request plan documents or benefit summaries

Obtain your complete 2025 prescription records and plan documents. These materials provide detailed medication usage patterns, supporting informed decisions for 2026.

Contact your insurance provider to request an annual benefits summary detailing total spending, medications filled, and benefit utilization. This documentation completes your prescription benefit audit, helping identify optimization opportunities for the coming year.

Plan Ahead for 2026 Savings

2026 presents specific opportunities to optimize prescription benefits and establish proactive medication management protocols. Post-audit strategies will maximize savings throughout the coming year.

Set up reminders for refill dates

Medication adherence affects both health outcomes and costs directly. Automatic refill reminder systems support year-round medication compliance:

Text alerts from pharmacies like CVS provide real-time updates when prescriptions are ready or need refilling
Walgreens' text system allows "REFILL" replies directly to reminder texts for instant processing

These reminder systems have been shown to increase cumulative refill rates by 22.8% within 14 days. Calendar alerts or medication reminder apps serve as additional safeguards against missed doses.

Explore Inside Rx and other discount programs

Inside Rx provides substantial savings potential for 2026 planning. This prescription discount program operates alongside existing insurance coverage:

Average savings up to 80% on thousands of brand and generic medications
Access to 60,000 participating pharmacies nationwide
Zero enrollment fees with no registration requirements

Inside Rx cannot be used for certain medications if you are enrolled in Medicare, Medicaid, or Tricare, though FSA funds may be applicable depending on your plan terms. To see the full list of discount restrictions visit InsideRx.com/discount-restrictions.

Talk to your provider about cost-effective alternatives

Healthcare providers now access tools displaying medication costs in real-time. SwiftRx® Direct helps physicians identify affordable alternatives to costly medications based on specific insurance benefits. One documented case shows a simple change from tablets to capsules reduced a patient's co-pay from $250 to $50.

Schedule a medication review appointment with your provider to discuss cost-saving alternatives before 2026 begins.

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Conclusion

Prescription benefit audits before December 31 prevent benefit forfeiture and prepare you for 2026 plan changes. This process identifies medication usage patterns, reveals cost-saving opportunities, and ensures optimal utilization of current benefits before plan resets.

The audit process prepares you for Medicare Part D adjustments and the 2026 deductible increases. Complete prescription records help you budget for upcoming plan changes and prevent unexpected expenses when coverage resets on January 1. Final refills, FSA fund utilization, and prescription history documentation preserve benefits that would otherwise expire. These actions prevent unused benefits from being forfeited when plans reset.

Refill reminder systems increase cumulative refill rates by 22.8% within 14 days while medication review appointments with providers can reduce expenses significantly. Inside Rx provides potential savings up to 80% on prescription medications at 60,000 pharmacies nationwide.

Prescription benefit audits require time investment but deliver measurable financial returns and improved medication management for 2026. The documentation and analysis completed now establishes a foundation for cost-effective healthcare decisions throughout the coming year.

References

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