The scope of the examination includes, but is not limited to, the PBM’s practices and procedures relating to the Pharmacy Benefit Manager activities. Please note that the definition of “Pharmacy benefits management” in accordance with the West Virginia Code Chapter 33, Article 51, Pharmacy Audit Integrity Act: “Pharmacy benefits management” means the performance of any of the following: (1) The procurement of prescription drugs at a negotiated contracted rate for dispensation within the state of West Virginia to covered individuals; (2) The administration or management of prescription drug benefits provided by a health benefit plan for the benefit of covered individuals; (3) The administration of pharmacy benefits, including: a. Operating a mail-service pharmacy; b. Claims processing; c. Managing a retail pharmacy network; d. Paying claims to a pharmacy for prescription drugs dispensed to covered individuals via retail or mail-order pharmacy; e. Developing and managing a clinical formulary including utilization management and quality assurance programs; f. Rebate contracting administration; and g. Managing patient compliance, therapeutic intervention and generic substitution program.
