PBM Audit Practices Under Scrutiny: What the House Inquiry Means for Independent Pharmacies

Pharmacy audits were originally introduced as being a legitimate safeguard for prescription drug benefits, but they demand substantial time and resources from the pharmacists responsible for delivering patient care. A new congressional inquiry asks whether some independent pharmacies faced that burden because they publicly supported pharmacy benefit manager (PBM) reform.

On October 23, House Oversight and Government Reform Committee Chairman James Comer (R, Kentucky) requested records and briefings from CVS Caremark, Express Scripts, and Optum Rx concerning potentially retaliatory audits. The inquiry follows pharmacy support for H.R. 6610, the Pharmacists Fight Back in Federal Employee Health Benefit Plans Act.

To be clear, these are allegations and warrant careful treatment but do shine additional light on concerns that independent pharmacies have been expressing for several years.

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What Congress Is Examining

The letters appear to describe different concerns corresponding with each PBM. For example, the Caremark letter references audit notices involving small prescription charges that allegedly arrived after their stated compliance deadlines. The Express Scripts letter raises concerns about closely spaced notices from several PBMs and deadlines preceding receipt of the notices. The Optum Rx letter describes pharmacies allegedly receiving their first audit notice, followed by 2 additional audits in quick succession.

Through this inquiry, the committee seeks audit selection methods, training materials, provider agreements, and audit totals concerning independent pharmacies nationwide with an affiliation breakdown. It also requests detailed audit records for independent pharmacies in Kentucky, Mississippi, and Florida. Staff briefings are requested by October 30, with documents due on November 6.

The records requested could help distinguish routine compliance activity from selective, targeted treatment. Of course, timing alone cannot establish retaliation but is one factor to be considered as part of this inquiry. Selection criteria, comparable pharmacies’ experiences, internal communications, and documented compliance concerns would provide a stronger basis for evaluating the allegations.

Distinguishing Legitimate Audits from Retaliatory Audits

Benefit plans have valid reasons to verify that billed prescriptions were dispensed, records support submitted claims, and contractual requirements were met. PBM provider manuals typically describe their audit programs as serving compliance roles and helping to prevent fraud, waste, and abuse.

But independent public oversight of PBM audit practices also demonstrates why truly effective auditing matters. An October 2025 New York State Comptroller report found shortcomings in Caremark’s auditing of the Empire Plan, including failures to perform certain contractually required pharmacy audits. The report recommended stronger audit selection and clearer responsibilities for identifying and referring potential fraud and abuse.

The policy question is therefore how to preserve meaningful oversight and ensuring that audit authority is exercised consistently and fairly. Moreover, even legitimate audits must still be conducted in a manner that complies with applicable law including as it relates to selection, scope, deadlines, or financial consequences.

For an independent pharmacy, responding can be exhausting and require personnel to retrieve extensive prescription records, invoices, delivery records, and correspondence while maintaining daily operations. Even when no repayment ultimately results, the response itself has a cost.

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Why Legislation Matters

H.R. 6610 addresses PBM practices in the Federal Employees Health Benefits (FEHB) Program. The committee previously advanced the measure, as amended, by a 40-2 vote on July 22.

The committee substitute would tie pharmacy reimbursement to acquisition-cost benchmarks, add a capped percentage payment and a state Medicaid-based professional dispensing fee, establish rebate requirements, and restrict steering and certain reimbursement reductions.

The committee’s audit inquiry, however, raises a separate concern: whether pharmacies can participate in debates over those policies without facing adverse treatment because of their advocacy. A credible reform process depends on lawmakers hearing from the businesses and clinicians most affected by existing practices without threat of retaliation.

What Pharmacy Owners Should Do Now

Pharmacies receiving unusual audit requests should build a clear factual record while continuing to meet applicable obligations. When needed, pharmacies should work with qualified representatives to support these efforts including qualified legal counsel.

Preserve the chronology. Retain notices, envelopes, email headers, portal messages, and proof of receipt. Record when the pharmacy first received each request and whether the stated deadline allowed a meaningful response. All of these details matter if there is any allegation of noncompliance by the PBM.

Track the operational burden. Document requested records, staff hours, overlapping demands, disputed findings, and amounts at issue. Specific records illustrating valid concerns are more useful than a general assertion that an audit was excessive.

Separate concerns from conclusions. Preserve relevant advocacy communications and compare audit activity before and after that advocacy. Describe observable events accurately; avoid assuming that a sequence of events proves retaliatory intent.

Protect response and appeal rights. Review the provider agreement, incorporated provider manuals, and potentially applicable state audit protections. Where needed, communicate and collaborate with qualified legal counsel. Application of state laws may depend on various factors including the plan, location, contractual language, and interplay with federal law. Seek deadline clarification if there is any doubt and, if needed, extensions should be requested promptly and in writing.

Escalate with care. Where the record supports valid concern, consider appropriate contractual, regulatory, or other legal channels. But these decisions should be made with care and appropriate caution.

A Fair Process Serves Patients

Federal scrutiny of pharmacy audits predates this inquiry. The Federal Trade Commission (FTC) expressly included potentially unfair audits of independent pharmacies in its 2022 PBM study. Its 2024 interim staff report subsequently identified concerns about contractual leverage and the disadvantages faced by unaffiliated pharmacies. Those broader concerns provide context; they do not establish the specific retaliation allegations now under examination. What, if anything, the requested records will reveal remains to be seen.

Effective audits and fair treatment should reinforce one another. Independent pharmacies should be accountable for their claims and free to contribute their experience to public policy. Protecting both interests supports the patients who rely on them.

For more insights on audits and what pharmacists can expect from their PBMs heading into 2027, check out our most recent episode of Pharmacy Law Lowdown with hosts Lee and Morgan, who painted a clear picture regarding approaches for defending against PBM inventory audits.

READ MORE: Law and Regulations Resource Center