Senate Bill 1000 Summary

• Health benefit payers must provide written notice at least 2 weeks before conducting on-site audits and cannot schedule audits during the first 6 calendar days of a month, holidays, weekends, or Mondays without pharmacy consent.

• Audits involving clinical or professional judgment must be conducted by or in consultation with a licensed pharmacist, and payers must identify audit procedures and appeals processes in pharmacy contracts.

• Health benefit payers cannot conduct extrapolation audits and must base recoupments only on actual overpayments found during the audit, excluding dispensing fees and not allowing contingency fees based on recovered amounts.

• Preliminary audit reports must be delivered within 60 days of audit completion, pharmacies receive 30 days to respond with documentation, and final reports must be delivered within 90 days; recoupments can only occur after the final report is delivered.

• Clerical and record-keeping errors do not constitute fraud without proof of intent to defraud, and pharmacies cannot be subject to recoupment unless the payer proves fraud intent or actual financial harm.