PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
WellDyne Pharmacy Audit: Response Strategy
WellDyne runs pharmacy audits with less formalized appeal infrastructure than major PBMs, which changes the response and negotiati…
Vaccine Billing Audits at the Pharmacy Counter
Administration fee billing, PREP Act authority, and the consent, screening, and lot documentation PBM auditors check during vaccin…
Spread Pricing: What It Means for Independent Pharmacies
How PBM spread pricing works, what the FTC's report found, and the state Medicaid laws requiring pass-through pricing for pharmaci…
Specialty Drug Audit Defense for Pharmacies
Why specialty pharmacies face heavier PBM audit scrutiny, and the network, accreditation, and REMS documentation that defends agai…
SmithRx Audit Defense for Independent Pharmacies
SmithRx markets transparent pricing, but its network agreement still sets audit, documentation, and recoupment terms independent p…
Refill Too Soon Audit Findings and How to Rebut Them
Why PBMs flag early refills, the legitimate clinical reasons that justify them, and the documentation that survives an audit.
Recoupment Offsets Against Future Claims: Your Options
When a PBM offsets a recoupment against future claims, the cash-flow hit starts immediately. What the withhold mechanic does, and…
Reading Your PBM Provider Manual Before the Audit
PBM provider manuals are incorporated into the network agreement and often decide audit disputes. What pharmacies should read befo…
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…