PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Pharmacy Audits of Topical and Compounded Pain Creams
Compounded pain creams draw outsized PBM audit scrutiny over reimbursement gaps, USP <795> paperwork, and prescriber marketing arr…
Pharmacy Audits of Part D Plan Sponsors Versus PBM Audits
A Part D audit's authority sits with the plan sponsor, not the PBM. Here is how CMS rules decide who audits a claim and which appe…
PBM Audit Findings on Delivery Signatures for Shipped Prescriptions
A missing delivery signature can now trigger a PBM recoupment on a mailed prescription. Here is what changed since the COVID-19 pu…
Inhaler and Insulin Pen Day Supply Errors
Inhalers and insulin pens dispense in fixed units that mismatch standard days supply math, a frequent trigger for PBM audit findin…
FTC Investigation of PBMs: What It Means for Your Pharmacy
The FTC has settled with two of the three largest PBMs over insulin pricing. Here is what changes, and what still does not change,…
Texas Pharmacy Audit Law: Rights When a PBM Audits You
Texas Insurance Code Chapter 1369 sets PBM audit notice, sampling, and anti-extrapolation rules, with limits set by ERISA and Medi…
Florida Pharmacy Audit Law and PBM Audits
Florida regulates PBM pharmacy audits through two statutes enforced by the Office of Insurance Regulation, with limits set by ERIS…
California Pharmacy Audit Rules and PBM Oversight
California law sets firm notice, lookback and appeal deadlines for PBM pharmacy audits, and routes new PBM licensure to DMHC, not…
Arkansas PBM Laws and Pharmacy Audit Protections
Arkansas regulates PBM audits through two statutes enforced by the Insurance Department, with limits set by ERISA and Medicare Par…