PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Discount Card Claims and PBM Audit Scrutiny
Discount card claims like GoodRx route through the PBM, and a mismatched usual and customary price can trigger a full-lookback PBM…
Central Fill and Audit Documentation Gaps
How DEA rules split prescription records between originating and central fill pharmacies, and where PBM audits find the gap betwee…
Challenging Extrapolation in a PBM Audit
How PBM extrapolation inflates a small audit sample into a six-figure recoupment demand, and the statistical and state-law objecti…
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.