HB 5981 Summary

• Health benefit payers conducting pharmacy audits must identify audit procedures in detail in the pharmacy contract and communicate any changes to the pharmacy.

• Health benefit payers must provide written notice at least 14 calendar days before initiating on-site audits and cannot schedule audits during the first 5 days of a month without pharmacist consent.

• Audits involving clinical or professional judgment must be conducted by or in consultation with a pharmacist, and recoupments or payment adjustments must be reasonable and proportional to the error detected.

• Health benefit payers are prohibited from conducting extrapolation audits and can only audit claims submitted within the 2-year period before audit initiation; preliminary audit reports must be delivered within 120 calendar days and underpayments must be reimbursed within 30 business days after final report delivery.

• Exceptions apply to audits involving fraud, willful misrepresentation, abuse, or criminal investigation, and conflicting provisions in the insurance code of 1956 take precedence over this section.