The PBM Issued a Final Determination. That Doesn’t Always Mean It’s Over.

Mark Boesen, PharmD, JD, is a licensed pharmacist and attorney and a founding partner of Boesen & Snow Law, with over three decades of experience in pharmacy operations, healthcare law, and public policy.

Mark K. Ziegler, Pharm.D., M.B.A., is Director of Payor Compliance & Credentialing at Boesen & Snow Law and a former PBM Audit Team Leader.

This is the last piece in our series on the PBM audit process. We’ve covered the notice and first submission, the discrepancy list, and the preliminary appeal. Here’s where most pharmacies stop paying attention, right after the final number arrives. That’s usually a mistake.

A Final Letter Isn’t Always Final

Once the appeal process runs its course, the PBM sends a final determination: a set dollar figure and whatever else comes with it. Most audits end here. But a final letter isn’t always the end of the road, and the PBM has no obligation to tell you that.

Many states legally require a PBM to let a pharmacy appeal a final finding, often within about 30 days of it being issued. Many PBM contracts also require the PBM to engage in a good-faith dispute process if a pharmacy wants to keep contesting the findings. Almost none of the pharmacies we talk to know either of these exists, and generally the PBM isn’t going to volunteer it.

Why Timing Decides Almost Everything Here

While not always the case, we have reopened final findings for pharmacies. Generally, what separates the ones we can help from the ones we can’t usually comes down to a single factor: how much time has passed.

A pharmacy that comes to us within that 30-day window, even with a large final number attached, has a better chance of getting the finding reopened, at least enough to make another case. It doesn’t guarantee a different outcome, but it can reopen the door. Compare that to a pharmacy that shows up five or six months after the final letter, hoping to appeal. By then the PBM has moved on, and the response is usually some version of “too late.” The finding itself may not be necessarily any different in either case. What’s different is whether anyone acted while the window was still open.

No one can guarantee anything at any stage of this process. But acting fast measurably improves your odds, and waiting past that window can close a door you didn’t know was still open.

What Can Follow a Final Finding

In some cases, a finalized discrepancy isn’t the last consequence. Depending on the size and nature of the findings, it can lead to network suspension or termination, a required corrective action plan, or a referral to a state board of pharmacy or federal regulator. In rarer cases, a pharmacy pursues arbitration or litigation instead of accepting the outcome. Most disputes resolve well before it gets that far. When it doesn’t, the dollar amount at stake and the underlying legal issue usually decide whether that path makes sense.

A network termination is also not always permanent. Terminations have been reversed or softened, but it depends on moving quickly, understanding the specific contractual and state-law grounds available, and addressing the PBM’s stated reasons rather than objecting to the outcome in general.

Understand Who You’re Actually Negotiating With

Once a dispute moves past the final letter, you’re generally not dealing with just an auditor anymore. The PBM’s own legal team typically gets involved. That’s the part most pharmacies don’t plan for, and showing up without the same kind of representation puts you at a real disadvantage from the start.

It’s why our audit team isn’t just pharmacist-attorneys who know these audit requirements cold. We work alongside litigation attorneys who can step in the moment a dispute reaches that level, so a pharmacy has someone on equal footing sitting across from the PBM’s counsel, not a business owner improvising against a legal team.

Where This Leaves You

Every stage of this process rewards speed and punishes delay, from the notice’s original deadline to this final, narrow appeal window. There are pharmacies out there getting audited every single day, and plenty of them that have been audited more than once. It isn’t a question of whether your pharmacy will face one. It’s a question of when, and whether you’re ready when it happens.

That’s really the thread running through this whole series. The pharmacies that come out ahead aren’t the ones who never face a discrepancy. They’re the ones who treat every stage (from the first notice to a final letter) with the same urgency, and who get help early enough for it to matter.

If you’d rather find out where your pharmacy stands before a notice ever arrives, that’s exactly what our PharmaFortify® program is built for. It puts your documentation, staff, and processes through the same kind of review a real PBM audit uses, on your schedule instead of theirs. And if you’re already mid-audit, the same rule applies at every stage in this series: the sooner we’re involved, the better this tends to go.

Attorney Advertising. This article is provided for general informational and educational purposes only and does not constitute legal advice. Contacting Boesen & Snow Law through this article does not create an attorney-client relationship. This content may constitute attorney advertising under the laws of your state. Prior results described or referenced herein do not guarantee a similar outcome.

Boesen & Snow Law is based in Scottsdale, Arizona. We work with independent, specialty, and multi-location pharmacies nationwide on PBM audit, network, and compliance matters. Our ability to formally represent a pharmacy in a particular matter, including litigation, arbitration, or before a state board, depends on that jurisdiction’s licensure and admission requirements, which may include pro hac vice admission or association with local counsel. Contact us to confirm we can assist with your pharmacy’s specific state and matter.