At Health Law Alliance, we work tirelessly to protect our clients from the devastating consequences that can result from adverse audit findings, from sky-high recoupments to unwarranted network terminations. Just this week, our team successfully obtained full reversal of adverse audit findings from CapitalRx, a pharmacy benefit manager with over $3.5 billion in annual revenue. This stunning reversal is the latest victory for our outstanding PBM audit attorneys, who leverage their unparalleled expertise in navigating PBM disputes to advocate for independent pharmacy owners across the country.
In May 2025, CapitalRx sent notice that it planned to recoup on numerous claims for thousands of dollars from an established Maryland pharmacy following a comprehensive desk audit earlier this year. Specifically, in its audit findings, CapitalRx cited to numerous documentation discrepancies and various recordkeeping violations, alleging that its audit revealed multiple instances of non-compliance with the terms of its provider manual. The pharmacy—which had previously submitted comprehensive documentation refuting these baseless allegations—sought Health Law Alliance’s legal expertise to challenge these erroneous findings and restore the Pharmacy’s reputation.
Winning the Battle: How Our Attorneys Achieved a Full Reversal of CapitalRx’s Audit Findings
Our knowledgeable healthcare defense attorneys know all too well that in PBM audit appeals, a robust, tailored strategy is the most effective way to address adverse audit determinations. Our team worked carefully to craft a comprehensive appeal response based on the pharmacy’s prior appeal submissions and internal records, making a point to reiterate that the pharmacy had appropriately submitted all supporting evidence in strict compliance with CapitalRx’s documentation guidelines. In its appeal, Health Law Alliance made clear that CapitalRx had failed to give due consideration to the pharmacy’s previously submitted evidence—which CapitalRx summarily ignored without explanation. This detailed response highlighted CapitalRx’s legal obligations to pursue the appeals process in good faith—requiring CapitalRx to reconsider the mountains of evidence that conclusively disproved each and every one of CapitalRx’s erroneous allegations.
This pattern is all too familiar to our PBM audit team. Day after day, independent pharmacy owners across the country receive audit findings that evidence PBMs’ striking disregard for the fairness of their own appeals processes, where evidence disputing inaccurate audit findings is conclusively disregarded, ignored, or dismissed without explanation. With our attorneys’ unmatched experience and understanding of the appeals process, our team crafted an intricate appeal response that conclusively resolved each of the purported discrepancies.
This week, CapitalRx notified the Pharmacy that it would be initiating a full reversal of its final audit findings. Our tireless advocacy not only protected the pharmacy from paying thousands in unjustified recoupments, but ensured that the pharmacy wouldn’t face even more severe consequences—including termination or referral to government agencies for potentially fraudulent practices.
HLA: Your Trusted Experts in PBM Audit Defense
In 2025, independent pharmacy owners already face a litany of challenges to navigate in order to stay afloat. At the same time, PBMs are growing bolder, attempting to recoup funds or even terminate pharmacies for increasingly specious reasons. In this environment, it’s never been more critical to have an experienced team of aggressive, experienced team of attorneys on your side. At Health Law Alliance, helping pharmacies navigate these challenges is our specialty.
If your pharmacy is facing adverse audit findings from a PBM, we’re here to help you every step of the way. Contact us today.
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