PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Health Law Alliance Secures a Reversal of OptumRx’s Network Termination for a California Pharmacy
Health Law Alliance recently secured a favorable outcome for a California independent pharmacy after OptumRx rescinded its decisio…
PBM Audit Defense Insights: Avoiding the Top PBM Audit Traps That Lead to Termination
For many pharmacies, a PBM audit begins as a routine request for records and ends with a startling realization: what appeared to b…
When “Retail” Isn’t Retail Enough: PBMs Increase Scrutiny of Mailed Prescriptions
Independent pharmacies have increasingly adapted their operations to compete with major pharmacy chains, finding ways to meet pati…
Health Law Alliance Successfully Prevents OptumRx Network Termination Following Pharmacy Audit
Independent pharmacies across the country continue to face aggressive scrutiny from Pharmacy Benefit Managers (“PBMs”) through aud…
Debunking 5 Common PBM Audit Myths That Put Pharmacies at Risk
For many independent pharmacies, receiving a PBM audit notice can feel like a routine administrative matter. But in today’s enforc…
Inventory Shortage Findings in PBM Audits: The Invoice Reconciliation Defense
PBM inventory shortfall findings often rest on incomplete wholesaler purchase files. Here is the invoice reconciliation defense th…
Desk Audits vs On-Site Audits: How PBM Review Types Differ
Desk audits and on-site PBM audits differ in document demands, notice timing, and escalation risk. Here is how the two review type…
How PBM Audit Findings Escalate to Network Termination
How a PBM audit finding becomes a termination for cause notice, the short appeal window that follows, and the risk of cross-networ…
Navitus Audits: What Pharmacies Should Know
Navitus Health Solutions audits pharmacies through desk and on-site reviews with strict deadlines. Here is how pharmacies should r…