PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Medication Synchronization and Prorated Fills in PBM Audits
Medication synchronization shortens fills to align refill dates. PBM audits flag the quantity and days-supply mismatch without the…
Documenting Prescriber Contact and Pharmacist Interventions
How pharmacies should record prescriber calls, clinical interventions, and refusal-to-fill decisions so they stand up as PBM audit…
Health Law Alliance Successfully Reverses OptumRx Network Termination for California Pharmacy
HLA secured the reversal of an OptumRx network termination for an independent California pharmacy after showing the audit findings…
Counseling Records and Patient Acknowledgments in PBM Audits
Some PBM audits involving Medicaid claims request counseling and acknowledgment records as a category separate from the signature…
Auditor Interviews of Pharmacy Staff: Rights and Preparation
What PBM onsite auditors may ask pharmacy staff, who should answer, when counsel should attend, and how to keep statements consist…
Adherence Packaging and Blister Pack Claims in PBM Audits
Multi-drug compliance packs face PBM scrutiny on packaging codes, days' supply, repackaged NDCs, and reversing claims for packs ne…
When a PBM Audit Finds Diversion Indicators
Early refills and pharmacy shopping in a PBM audit can prompt a referral to law enforcement, with separate DEA and state reporting…
Patient Pay Amount Findings and Copay Waivers in PBM Audits
Caremark audits now flag copay waivers as a distinct finding from collection gaps. Here is what financial hardship documentation C…
Pharmacy Audits Triggered by Prescriber Sanctions
PBMs now screen prescribers against federal exclusion and preclusion lists. Here is how a pharmacy cures or contests a sanctioned-…