Independent pharmacies have increasingly adapted their operations to compete with major pharmacy chains, finding ways to meet patients’ demand for convenience and accessibility. For many, that includes mailing prescriptions to patients who are elderly, homebound, immunocompromised, or otherwise unable to visit the pharmacy in person. But a growing trend in Pharmacy Benefit Manager (“PBM”) audits suggests that some PBMs are now treating routine mailing activity as a basis for recoupment, network discipline, or even termination, even where state law protects a pharmacy’s ability to mail prescriptions to patients.
The Expanding Scope of PBM Audit Scrutiny
PBM audits have become significantly more aggressive in recent years. Pharmacies are seeing increased scrutiny not only of traditional documentation issues, but also of operational practices that PBMs previously tolerated or ignored.
In some audits, PBMs have demanded extensive documentation regarding shipping practices, patient communications, delivery logs, and business licensure to assess pharmacies’ dispensing patterns. In others, PBMs have used even isolated mailings to patients to allege that pharmacies improperly billed claims through retail networks, arguing the mailing violates their agreement based on their retail pharmacy designation. The financial exposure can be substantial, with PBMs seeking recoupments tied to every mailed prescription identified during the audit period.
Why PBMs Are Focusing on Mailing Activity
PBMs increasingly use data analytics to identify dispensing patterns they consider “outliers,” including pharmacies shipping medications across state lines or dispensing a high percentage of mailed prescriptions. At the same time, many PBMs maintain separate retail and mail-order networks with different credentialing requirements and reimbursement structures. Many also operate affiliated mail-order pharmacies themselves and may view independent pharmacies offering shipment services as competing with preferred dispensing channels.
As a result, many PBMs include provisions in their network provider agreements that prohibit pharmacies from mailing medications to members. But in 2026, many states have passed legislation protecting pharmacies’ ability to ship medications to patients upon a patient’s request, with some preventing PBMs from imposing any restrictions on pharmacies’ shipping practices. Similarly, several states have enacted anti-steering laws designed to prevent PBMs from discriminatory treatment that favors their own mail-order pharmacies.
Despite this, PBMs continue to challenge pharmacies’ mailings of medications to members, frequently citing these claims in audit findings or as grounds for termination.
A Trend Pharmacies Cannot Ignore
The increasing focus on mailed prescriptions reflects a broader reality in today’s PBM environment: audits are no longer limited to traditional documentation deficiencies. PBMs are increasingly scrutinizing mailed prescriptions as a tool to claw back thousands of dollars from pharmacies, even when their mailing practices are protected by state law. For pharmacies that utilize delivery or shipment models, proactive review of contracts, policies, and documentation procedures is critical to evade PBM scrutiny.
Health Law Alliance has substantial experience helping pharmacies fight back against PBMs’ unjust audit findings. Whether your pharmacy is in the initial stages of an audit or challenging a network termination, our team leverages our tried-and-true appeal strategies to protect your business. Contact us today for a free consultation.
