PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Proof of Delivery Requirements in a PBM Audit
PBM audits increasingly hinge on proof a prescription reached the patient. What counts as delivery documentation, and where the ga…
Prior Authorization Documentation in PBM Audits
A PBM's own prior authorization approval does not close the file. When documentation questions surface in an audit, the burden oft…
Prescriber Verification Findings and How to Cure Them
When a PBM cannot verify a prescriber, the claim can trigger recoupment. Here is how pharmacies document and cure these audit find…
Pharmacy Credentialing Denials and Re-Credentialing Traps
PBM credentialing denials and re-credentialing rejections can cascade into terminations across every network a pharmacy depends on…
PBM Arbitration Clauses: Where Your Dispute Actually Goes
Many PBM provider agreements require arbitration, not court, for recoupment and network termination disputes. Here is how that act…
Network Termination Without Cause: Do You Have Recourse
A PBM's without-cause termination clause looks absolute, but state notice rules and rational-basis requirements can still open a p…
Magellan Rx Pharmacy Audit Defense
Magellan Rx audits pharmacy claims for commercial and Medicaid managed care plans, creating dual exposure under PBM and state prog…
Mail Order Versus Retail: Why PBMs Audit Shipped Prescriptions
PBMs treat retail and mail order pharmacies as separate networks. Shipping prescriptions without the right documentation can trigg…
MAC Appeals: Challenging Below-Cost Reimbursement
State MAC appeal statutes, the short filing windows PBMs impose, and the wholesaler invoice record a pharmacy needs to challenge b…