PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
DAW Codes 0 Through 9: What Each Code Tells the PBM
How DAW codes 0 through 9 tell a PBM who chose a brand over a generic, and what the hard copy has to show to back up the code.
Health Law Alliance Protects Independent Pharmacy from Network Termination After PBM Audit
Health Law Alliance defended a community pharmacy facing potential OptumRx network termination after an audit. The pharmacy kept i…
How a Minor PBM Audit Finding Can Put Your Pharmacy’s Network Status at Risk
A single PBM audit finding, such as a missing invoice or an incomplete signature log, can become the basis for a network terminati…
When PBM Audit Findings Escalate: CMS Referrals, UPIC Audits, and Broader Pharmacy Risk
Adverse PBM audit findings can lead to CMS referrals, UPIC audits and Board of Pharmacy scrutiny. Why the first response and the a…
AWP, WAC, NADAC and MAC: Pharmacy Pricing Benchmarks Compared
AWP, WAC, NADAC and MAC are set by different parties and measure different things. Here is what each means for a pharmacy's reimbu…
DAW 1 and DAW 2 Findings in a PBM Audit
A PBM audit can recoup a DAW-1 or DAW-2 brand claim when the file has no prescriber notation that the brand is medically necessary…
Your PSAO's Role in a PBM Audit
A PSAO holds the network contract behind a PBM audit and often handles the notice and remittance, but the response deadline and pr…
Reversing and Rebilling Claims After a PBM Audit Notice
Reversing and rebilling a flagged claim after a PBM audit notice can read as concealment, not correction, under how provider manua…
State Pharmacy Audit Laws and When They Apply to a PBM Audit
Most states protect pharmacies during PBM audits through their own audit statutes, but a self-funded plan's ERISA status can chang…