California CodesBusiness and Professions Code - BPCDivision 2 — Healing ArtsChapter 9.5 — Audits of Pharmacy BenefitsSection 4436
(a) A pharmacy audit that involves clinical judgment shall be conducted by, or in consultation with, a licensed pharmacist.
(b) An entity conducting a pharmacy audit shall make all determinations regarding the legal validity of a prescription or other record consistent with determinations made pursuant to Article 4 (commencing with Section 4070) of Chapter 9.
(c) Nothing in this section shall be construed to prohibit a pharmacy benefits manager from denying a claim, either in whole or in part, for failure to comply with federal Food and Drug Administration or manufacturer requirements, the prescription drug formulary, prior authorization requirements, days’ supply requirements, or other coverage or plan design requirement, or for failure to include a National Provider Identification number.
(d) An entity conducting a pharmacy audit shall accept paper or electronic signature logs that document the delivery of pharmacy services to a health plan beneficiary or his or her agent.
Notes
Requires pharmacy audits involving clinical judgment to be conducted by or with a licensed pharmacist, requires prescription-validity determinations to follow the specified law, and requires acceptance of paper or electronic delivery-signature logs. A pharmacy benefits manager may still deny claims for listed FDA, manufacturer, formulary, prior-authorization, days-supply, plan-design, or National Provider Identification failures.
Use as reference
Lexinter.net | California Code, Business and Professions Code - BPC § 4436 | https://laws.lexinter.net/codes/california/business-and-professions-code/division-2/chapter-9-5/section-4436