State Compliance Audits for Pharmacy Programs

Pro Pharma performs State Compliance Audits for Health Plan Pharmacy Programs. The compliance audits reference applicable state regulatory code criteria. Both the Plan and the PBM are issued requests for documentation to support code compliance, delegation to the PBM, and summary bulleted information to help guide the audit.

Codes are evaluated with specific emphasis on all parts of each code. This allows for review of policies with language that complies with the code and documentation specific to the code indicating implementation.

Pro Pharma takes the following steps to address gaps in compliance:
• Review each code and request Policy & Procedure documentation
• If needed, Pro Pharma assists the PBM with appropriate language consistent with the codes
• Request letters and implementation documents to demonstrate actions consistent with State Compliance Rules & Regulations.
• If required documents or letters are not available, Pro Pharma provides language and assists the PBM with the required implementation documentation