PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Return to Stock and Unclaimed Prescriptions in PBM Audits
A paid claim never picked up is a classic PBM audit finding. The reversal timing and will-call records a pharmacy keeps decide whe…
Reading an OptumRx Network Termination Notice
An OptumRx network termination notice states a reason, a cited provision, and an effective date. Here is how to read each part and…
Reading a CVS Caremark Network Termination Notice
A CVS Caremark network termination notice states its own grounds, for-cause or without-cause status, and effective date. Here is h…
Pharmacist-Prescribed Claims in PBM Audits: Naloxone, Test-and-Treat and Contraception
Naloxone, test-and-treat and contraception claims bill under a pharmacist's own prescribing authority, and PBM audits are flagging…
Express Scripts Desk Audit Packet Checklist
A claim-by-claim checklist for organizing prescription images, signature logs, invoices, and prescriber notes for an Express Scrip…
Expired Prescriptions and Refills Beyond Authorization in PBM Audits
A PBM audit tests prescription validity and refill counts; the federal controlled-substance limit and the state general limit are…
ERISA Preemption and State PBM Laws: What Pharmacies Can Enforce
Rutledge v. PCMA and PCMA v. Mulready mark where ERISA preempts state PBM audit and network laws, and where a pharmacy can still e…
Building a PBM Audit Response Binder, Claim by Claim
A claim-by-claim binder, indexed to the PBM's own numbers, turns a chaotic audit response into evidence that holds up on appeal.
Auto-Refill Programs and PBM Audit Exposure
Auto-refill and refill-reminder programs create their own PBM audit findings: unrequested fills, missing consent records, and stoc…