How To Prepare for a PBM Pharmacy Audit in Illinois

 Posted on December 05, 2025 in PBM Pharmacy Audits

If you own or manage a pharmacy, a notice of a PBM audit can come as an unwelcome surprise. Even a routine audit can feel intimidating, especially if you are unsure what to expect. The results may affect your payments, your reputation, or even your professional license. At The Law Offices of Joseph J. Bogdan, Inc., we can help you understand the audit process and prepare. Contact our experienced Rockford, IL PBM pharmacy audit defense lawyer to discuss your legal options.

What Triggers a PBM Audit in Illinois?

PBMs usually begin an audit when they see billing patterns that seem unusual. This might include a high number of refills, frequent claim adjustments, or a large volume of costly medications. Sometimes an audit starts after a complaint from a patient, a doctor, or an insurance company.

There are three main types of PBM audits:

• Desk audits happen remotely, where you send documents to the PBM.

• On-site audits involve auditors visiting your pharmacy.

• Post-payment audits occur after you have already been paid for claims.

Each type of audit can have an impact on your business. Even minor recordkeeping issues or misunderstandings may prompt follow-up questions or requests for clarification. 

What Documents Do PBMs Usually Ask For During an Audit?

PBMs often ask for detailed records to verify that your pharmacy follows state and federal rules. This includes prescription logs, patient signatures, dispensing records, and invoices from wholesalers. They may also want to see delivery slips or notes from patient counseling sessions.

Under the Illinois Pharmacy Practice Act, pharmacies must keep complete and accurate records for at least five years. If a document is missing or hard to read, the PBM might need extra clarification before approving a claim. Taking time to keep your records neat and easy to find shows that your pharmacy takes compliance seriously and is committed to serving patients with care and professionalism.

How Should You Prepare For a PBM Audit?

You can prepare for an audit long before you receive notice. Review your recordkeeping system often to make sure all information matches across prescriptions, invoices, and inventory logs. Check that every prescription label, signature, and refill note is complete. Train your staff so they know how to handle auditor requests and respond politely. Make sure all communications are documented.

What Are Common Mistakes Pharmacies Make During a PBM Audit?

Some issues happen because of everyday mistakes, not because anyone meant to do something wrong. Sending in paperwork that is missing pages, updating information after the audit begins, or missing a response deadline can make the process more stressful. Small inconsistencies in your records can also create confusion.

Because audits often focus on documentation and storage practices, you want to understand what the law expects from you. Under 225 ILCS 85/30, Illinois pharmacies must follow all laws for dispensing and storing medications. For example, an incomplete controlled substance log or a missing invoice may lead to extra questions from auditors. Taking time to review your records on a regular basis can help you catch small errors early and show that your pharmacy is committed to accuracy and good patient care.

Contact a Rockford, IL PBM Pharmacy Audit Attorney Today

Attorney Joseph Bogdan offers both legal and pharmaceutical experience to his clients. He is a registered pharmacist and an attorney, giving him insight into how audits work from both perspectives. He also serves as an expert witness in cases involving pharmacy regulations and controlled substances. With more than 20 years of experience, he understands what PBMs look for and how to respond effectively.

If you have been contacted for an audit or if you are preparing for one, contact an East St. Louis, IL PBM pharmacy audit defense lawyer today. Call The Law Offices of Joseph J. Bogdan, Inc. at 630-310-1267 to schedule your free consultation.