A discount card claim, filled through GoodRx, SingleCare, or a similar program, still adjudicates through the pharmacy's contracted pharmacy benefit manager. The price on that claim can become the evidence a PBM audit team uses to challenge the pharmacy's usual and customary (U&C) price. When the U&C price on standard claims does not reflect the price the pharmacy actually accepts through a discount card, PBM audit teams treat the gap as a pricing violation, and the resulting recoupment can reach back across the full audit lookback period.
How Discount Card Claims Reach the PBM
Discount card programs do not create a true cash transaction. The card routes the prescription through the PBM's own adjudication system, at a rate the PBM negotiates with the discount card operator, often below the pharmacy's standard reimbursement. In January 2025, the National Community Pharmacists Association joined a class action against GoodRx, CVS Caremark, Express Scripts, MedImpact, and Navitus alleging the companies route discount-card transactions to whichever PBM offers the lowest pharmacy reimbursement, then split a per-transaction fee. Whatever that litigation resolves, the underlying mechanism is not contested: a discount card claim is a PBM-adjudicated claim, and it sits inside the same data set reviewed during a PBM audit.
The Usual and Customary Pricing Exposure
Most PBM contracts define the U&C price as the amount the pharmacy would charge a cash customer for the same drug, same quantity, same day. In United States ex rel. Schutte v. SuperValu, decided by the Supreme Court on June 1, 2023, whistleblowers alleged that SuperValu and Safeway submitted a full retail price as U&C while routinely accepting a lower, discounted price through a price-match program. The Court held that False Claims Act liability turns on whether the pharmacy knew or believed the discounted price was its real U&C price, not on the court's own reading of the contract. The same exposure applies to discount card pricing: a pharmacy that accepts a discount card rate as its effective going price builds a pricing record an auditor can use against it.
What PBM Audits Look For
PBM audit teams pull a pharmacy's claims history alongside its discount card adjudication data and compare the two. A pattern of claims where the discount card price is consistently lower than the submitted U&C price is a flag for review, and audit manuals typically treat repeated, predictable discounting as evidence the lower price is the pharmacy's real U&C. Programs such as Express Scripts' Price Assure and OptumRx's Price Edge now capture some of this automatically, applying the lower discount-card price to the claim at adjudication. That reduces exposure on the flagged claim itself, but it also builds a running record of the pharmacy's actual cash pricing that an audit team can use for a broader U&C finding.
Recoupment and Network Consequences
A U&C finding rarely stays limited to the claims actually reviewed. PBM auditors commonly extrapolate a sample finding across the full lookback period, turning a handful of flagged discount card claims into a six-figure recoupment demand. The mechanics of that process are covered in What a PBM Audit Really Costs: Extrapolation and Recoupment Explained. Walgreens learned the cost of this exposure directly: in a January 22, 2019 settlement, Walgreens paid $60 million to resolve allegations that it failed to disclose its Prescription Savings Club discount pricing as its Medicaid U&C price for conduct spanning 2008 to 2017.
Where the PBM's methodology is flawed, an audit appeal remains the pharmacy's primary procedural check, but the record built at that stage still starts with the same pricing data the audit team already reviewed. A pattern the PBM characterizes as a systemic pricing misrepresentation can also become the PBM's stated basis for network termination.
A discount card claim is a PBM-adjudicated claim, and the price paid on it becomes part of the record a PBM audit team uses to test a pharmacy's usual and customary price.
Why Early Legal Counsel Is Critical
It is critical that pharmacies promptly retain experienced healthcare defense counsel upon receiving a PBM audit notice, a discount card pricing inquiry, or any request tied to usual and customary pricing. Early legal intervention can protect the pharmacy's rights, ensure the audit response accurately reflects how discount card claims were priced and disclosed, and avoid inadvertent admissions. Delaying legal representation can significantly affect the outcome of the audit and expose the pharmacy to unnecessary recoupment and network risk.
How Health Law Alliance Can Help
Health Law Alliance has overseen 2,000+ PBM audits, including matters where discount card and usual and customary pricing discrepancies drove the recoupment demand. We review how a pharmacy's discount card pricing was captured, disclosed, and defended, and build the documentation record a PBM audit team requires before it will withdraw or reduce a finding. If your pharmacy has received a PBM audit notice involving discount card claims, our PBM audit defense team can review the notice. Contact us today for a free consultation.
