Pharmacy and PBMs

Pharmacy benefit managers administer prescription-drug benefits on behalf of Medicaid agencies and managed care plans. Audit work considers contracting, pricing practices, claims administration, transparency, and oversight of pharmacy vendors.

Complex payment flows between agencies, health plans, benefit managers, and pharmacies can make the final cost of a prescription difficult to trace. Auditors examine whether contract terms protect Medicaid funds and whether reported pharmacy expenses reflect the amounts actually paid.

1. CarelonRx overall completion is in compliance (99.76% cumulative), but sections note missing or potentially missing voids and CDJ transactions in certain months that could overstate or understate completion in February 2025 and September 2024.

   Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care · Myers and Stauffer LC · May 21, 2026

2. Significant improvement needed in MDHHS's PBM contract monitoring plan and written monitoring procedures for contract SLAs.

   Efforts to Monitor Established Service Level Agreements for the Medicaid Pharmacy Benefits Manager Contract · Michigan Office of the Auditor General · Mar 25, 2026

3. Michigan ensured that the managed care organizations followed all outpatient prescription drug coverage and utilization requirements that were in place during our audit period, including prior authorizations and quantity limits, for all 105 encounter claims in our stratified random sample.

   Selected Diabetes and Weight Loss Drugs Were Dispensed to Michigan Medicaid Managed Care Enrollees in Accordance With Federal and State Requirements · U.S. Department of Health and Human Services Office of Inspector General · Mar 2026

1. Update instructions to disallow non-medical costs of third-party vendors, including PBMs.

   Oregon Medicaid Managed Care Medical Loss Ratio Audit · Centers for Medicare & Medicaid Services · Mar 1, 2023

2. Implement its performance audit plan, including audits of pharmacy benefit managers.

   Medicaid Managed Care Contract Processes at the Health and Human Services Commission · Texas State Auditor's Office · Jan 19, 2019

3. Work with CarelonRx to (re)submit any potentially missing or corrected encounters and CDJ transactions, including voids.

   Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care · Myers and Stauffer LC · May 21, 2026

• Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care
• Selected Diabetes and Weight Loss Drugs Were Dispensed to Michigan Medicaid Managed Care Enrollees in Accordance With Federal and State Requirements
• Efforts to Monitor Established Service Level Agreements for the Medicaid Pharmacy Benefits Manager Contract
• Missouri Medicaid Rebates for Physician-Administered and Pharmacy Drugs
• Follow-Up Assessment on a Previously Published Audit Report Managed Care Pharmacy Claims Paid to Encore Pharmacy #1
• Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024
• Managed Care Pharmacy Benefit Services – Aetna
• Managed Care Pharmacy Benefit Services – Wellpoint
• Managed Care Pharmacy Encounters Paid to Omnicare Pharmacy
• Managed Care Pharmacy Encounters Paid to Meadowbrook Pharmacy
• Performance Audit Report: Pharmacy Benefit Manager Services for the Physical HealthChoices Medicaid Program in Pennsylvania
• Maryland Department Of Health Pharmacy Services Audit Report
• Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
• Poor Accountability and Transparency Harm Medicaid Patients and Independent Pharmacies
• Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program
• Oregon Medicaid Managed Care Medical Loss Ratio Audit
• Managed Care Pharmacy Claims Paid to ReCept Pharmacy #1
• An Audit Report on Cook Children’s Health Plan, a Managed Care Organization
• An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
• Medicaid Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare
• Analysis of Selected Medicaid Claims Data
• An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Department of Social Services Prescription Drug Oversight