Following Frier Levitt’s webinar, “Navigating the Pathway to Maintaining PBM Network Compliance,” attendees submitted a series of questions that reflected the real-world compliance challenges pharmacies face today. Many of these questions focused on PBM audit standards, network fairness, documentation requirements, member denials, copay collection, delivery restrictions, appeal deadlines, and anticipated regulatory reforms.
To provide additional clarity, Partners Harini Bupathi and Eric Knowles have prepared the following responses. This Q&A expands on the key points covered during the session and offers practical guidance to help pharmacies strengthen their compliance posture, address audit discrepancies, and protect their PBM network relationships as they move into 2026.
Question 1: Do you feel that the PBMs audit/treat their vertically integrated networks the same?
Answer: In practice, PBMs state that they apply uniform standards across their networks. However, independent pharmacies frequently report perceived differences in scrutiny, extrapolation, and recoupment posture when compared to PBM-affiliated or vertically integrated pharmacies. Regulators have been examining PBM vertical integration and its effects on network fairness. For example, the House Committee on Oversight and Accountability, the Federal Trade Commission, and the Oklahoma Attorney General have all claimed that PBMs favor their affiliated pharmacies over independent pharmacies after reviewing data that has been made available. We also often see this translate into issues surrounding network compliance and PBM audits. For example, if an independent, retail pharmacy faced a Board of Pharmacy action, however minor, it is required to report it and could face network review, but if a PBM’s wholly owned pharmacy faced a similar action, it would likely not face any repercussions.
Question 2: If a patient is unable to sign the signature pad at the pharmacy, what documentation should the pharmacy obtain to counter member denials?
Answer: With respect to confirming patient receipt, it is important to review any Board of Pharmacy and PBM requirements as to documentation requirements. Generally, it is required to maintain some proof of patient receipt, particularly if the patient picked up the prescription at person, but if the patient was unable to sign the pad, then there should be other forms of documentation that indicate why a patient may not have been able to sign (e.g. physical limitation), signature of staff, time, date, etc. That said, should a patient nevertheless deny receiving or requesting a prescription, we often advise obtaining a member attestation that clearly confirms the patient’s request and/or receipt. Typically, PBMs identify the requirements of the elements of such attestations as well with their audit results or in their Provider Manual.
It may help to have a well-documented “signature exception” process that creates a reliable audit trail. Elements could include:
- Signature exception form: Note why the patient could not sign (e.g., physical limitation), the date/time, Rx number(s), staff name and title, and the verification method used.
- Attestation: Have the patient sign an attestation at a later date which affirms the medication the patient received and clearly states the date in which the patient received the medication.
- Alternate attestor: Caregiver/authorized representative signature when available, with relationship and contact information. If using a facility, obtain a facility staff signature on a delivery/receipt log.
- System artifacts: POS transaction logs, time-stamped dispensing and counseling documentation, and any workflow notes that corroborate pickup.
- Deliveries: For deliveries, use carrier tracking with delivery address, date/time, and signature or a documented no-signature exception consistent with payor terms and conditions.
Again, importantly, these should be consistent with the terms and conditions of any PBM Provider Agreements and Manuals and applicable law.
Question 3: Can member denials and member attestations be used in Long Term Care pharmacy?
Answer: Generally, member denials should be resolved by member attestations, even in the LTC setting, but facility-based documentation is important as well. PBMs typically expect pharmacies to maintain: facility receipt logs (for delivered meds), MAR/eMAR documenting administration, prescriber orders and cycle-fill records, and return/destruction logs where applicable.
Question 4: Not all pharmacies deposit checks regularly. Will PBMs penalize us if we deposit the checks 2–3 months after they’re issued?
Answer: Understanding that this question is related to the deposits of checks for copayments, it is important to ensure timely deposit of checks upon receipt. This is particularly important since a copayment is not considered “collected in full” until a deposit of the check is made. If a pharmacy significantly delays depositing a check, the check could become void, or the PBM could even initiate an audit in the interim.
Question 5: Have you had any success with Optum and their no mailing during an audit and requiring a w-2 employee only.
Answer: Since the PHE for COVID-19 expired in 2023, OptumRx has required its retail pharmacies to deliver medications by way of a W-2 delivery driver and not engage in mailing. That said, we have been able to obtain some exceptions to this limitation on behalf of pharmacies, depending on the state in which they are located in and any other unique circumstances.
Question 6: If a pharmacy received a termination notice from a PBM and did not meet the appeal deadline is it still worth responding to the appeal?
Answer: Yes. While missing a contractual deadline may waive certain, formal appeal rights, a timely, well-supported request for reconsideration can still be productive. Steps to consider:
- Submit a concise explanation of good cause for the delay and the merits (corrective actions, remediation, compliance improvements).
- Ask in writing for discretionary reconsideration or informal resolution and escalate per any alternative dispute resolution provisions in the manual.
- If termination affects government program networks, consider whether any regulatory complaint pathways exist in your jurisdiction.
- If reinstatement is not available, seek guidance on recredentialing timelines and prerequisites, and document your compliance enhancements.
Question 7: Do you anticipate Congress passing any meaningful legislation that will regulate PBMs?
Answer: There is sustained, bipartisan interest in PBM reform, focused on transparency, spread pricing, rebate practices, and audit standards. The legislative outlook remains fluid, but incremental reforms at the state level are more likely than sweeping national overhauls in the near term. Expect continued activity through committee work and potential narrower packages addressing transparency, pass-through requirements, and audit parameters rather than comprehensive restructuring.
Question 8: If a pharmacy receives a favorable CAP result and the plan rescinds the revocation document due to their error, is the pharmacy required to disclose it?
Answer: It depends on the pharmacy’s requirements under their PBM terms and conditions. Many times, Provider Manuals and Agreements provide definitions as to what may constitute disciplinary action or network terminations that may require disclosure. Alternatively, some PBMs purposely keep such wording vague and broad, which could require legal expertise to navigate the obligations to disclose any actions to the PBM. Ultimately, a pharmacy should provide accurate responses to any PBM inquiries and ensure that all required disclosures are made in a timely manner in accordance with the PBM’s terms and conditions.
How Frier Levitt Can Help
Frier Levitt has extensive experience guiding pharmacies through every stage of PBM interaction from routine audits to high stakes terminations. Our attorneys include former prosecutors, litigators, and clinicians who understand the operational and regulatory pressures pharmacies face. Whether your pharmacy is confronting a time sensitive termination, looking to strengthen its compliance posture, or preparing for upcoming audits, our team can provide the guidance needed to protect your business. Contact our team for your pharmacy needs.
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