At Health Law Alliance, defending pharmacy providers from unwarranted terminations by PBMs isn’t just a part of what we do - it’s what we know best. This month, our attorneys’ tireless advocacy resulted in Optum rescinding its decision to terminate a New York pharmacy. This monumental reversal is just one of a series of victories from our PBM audit team, who specialize in employing strategic, tailored expertise to fight back against the largest PBMs in the nation - and win.
In June 2025, OptumRx moved to terminate a New York pharmacy from its network following a desktop audit, citing noncompliance with Optum’s pharmacy provider manual. Specifically, Optum cited inventory discrepancies and isolated purchases from a non-accredited wholesaler - purchases which accounted for less than 0.3% of the pharmacy’s total claims during the audit period - as grounds for its decision to terminate the pharmacy. The pharmacy, which had served in Optum’s network for over a decade, retained Health Law Alliance to appeal Optum’s termination.
From Termination to Reinstatement: The Legal Strategy That Reversed Optum’s Decision
Having served hundreds of pharmacies across the nation, our team of expert healthcare defense attorneys utilized its tried-and-true strategy for preparing effective PBM audit appeals: leveraging the pharmacy’s dispensing data and inventory purchase histories to create a comprehensive, robust appeal. In the appeal, Health Law Alliance emphasized that Optum’s termination was a disproportionate and draconian response to minor and remediable issues. Optum claimed that termination was warranted based on allegedly “discrepant” claims that comprised less than 1% of Optum’s total reimbursements to the pharmacy in 2024. Further, our attorneys highlighted that in calculating the pharmacy’s inventory, Optum had failed to account for numerous medications that had been purchased prior to the audit period, which Optum summarily ignored without explanation. The appeal emphasized that termination over minor errors, which the pharmacy rectified by implementing comprehensive inventory purchasing protocols tailored to Optum’s concerns, was not only unjustified, but a clear breach of Optum’s legal and contractual obligations.
In August, Optum agreed to rescind its decision to terminate the pharmacy, allowing the pharmacy to remain a provider of Optum’s networks and protecting the pharmacy’s longstanding reputation. Our successful appeal protected the pharmacy from significant financial harm, allowing the pharmacy to continue serving Optum patients with confidence.
Facing Termination? HLA Can Help
Independent pharmacy owners call us every day facing erroneous audit findings and unjust terminations from some of the nation’s most powerful PBMs. At Health Law Alliance, our expert attorneys have years of proven experience protecting pharmacies from PBM overreach. Our recent victory over Optum is just one example of our team’s dedication to ensuring justice is served.
Received a termination notice from a PBM but not sure where to start? That’s where we come in. We’re here to help you navigate the appeal process with confidence. Contact us today.
MORE ARTICLES BY CATEGORY
California Hospice Fraud Crackdown: What it Means for Providers & How to Protect Your Business
California’s hospice fraud crackdown is only the beginning of what CMS and Medi-Cal regulators have claimed will be many more cases brought against hospice facilities and home health agencies. Providers who do not timely respond to a suspension or revocation may waive important rights. Act now to protect your business and reputation from governmental overreach based on data mining and other unreliable sources.
Read More >>The WISeR Model: A New Era of Prior Authorization and Audit Risks for Wound Care
On January 1, 2026, the Centers for Medicare & Medicaid Services (CMS) officially launched the Wasteful and Inappropriate Service Reduction (WISeR) Model. This initiative is not just another administrative hurdle; it is a technology-driven enforcement overhaul aimed directly at the wound care industry.
Read More >>OMIG Audit Defense New York: What the 2026 Work Plan Means for Providers
Every year, the New York Office of the Medicaid Inspector General (OMIG) releases its Work Plan outlining enforcement priorities. The 2026 plan sends a clear signal that Medicaid providers in New York are entering a far more aggressive enforcement environment.
Read More >>PBM Member Denial Audit Findings: A Growing Threat to Pharmacies
Pharmacies undergoing a Pharmacy Benefit Manager (PBM) audit are typically prepared to address inventory discrepancies and documentation issues. What many are not prepared for, however, is the increasing use of PBM member denial findings, allegations that a patient claims they did not receive and/or did not authorize the dispensing of a medication for which a claim was submitted.
Read More >>
