Pharmacy benefit manager (PBM) audits continue to face heightened scrutiny as questions grow regarding their purpose and impact on pharmacies. While audits are often described as tools for ensuring compliance and preventing fraud, waste, and abuse, critics argue they are also used to generate revenue, justify network terminations, and steer patients to PBM-affiliated pharmacies. At the same time, recent federal PBM reform measures are increasing oversight of PBMs and raising new questions about how audit recoveries and pharmacy relationships will be scrutinized going forward.
In Part 2 of a series with Drug Topics, Harini Bupathi discussed the motivations behind PBM audits and how the Consolidated Appropriations Act of 2026 (CAA 2026) could influence future audit practices.
“While yes, some audits are used mostly to generate revenue for the PBM, and of course that’s a revenue stream for PBMs, it’s certainly to be able to limit their pharmacy networks as well.”
Harini explained that although CAA 2026 does not directly alter the mechanics of pharmacy audits, increased oversight of PBMs could affect how they monitor network pharmacies and create greater visibility into how audit recoveries are handled.
