PBM Audits & Defense
Network audits, recoupments, terminations, and appeals against Caremark, OptumRx, Express Scripts, and other PBMs.
Prime Therapeutics Audits: Findings, Deadlines, and Appeals
A guide to how Prime Therapeutics conducts desk and on-site pharmacy audits, the 30-day appeal deadline, and defenses pharmacies c…
From Desk to Courtroom: When a PBM Audit Leads to a Legal Battle
For many pharmacies, a PBM audit begins innocently enough. A letter arrives requesting prescription records, invoices, proof of de…
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Health Law Alliance recently secured a favorable outcome for a California independent pharmacy after OptumRx rescinded its decisio…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…