The Ohio Senate today passed Senate Bill 258, sponsored by Senator Troy Balderson (R–Zanesville), which establishes standards for the oversight of pharmacy audits in Ohio.
“My main objective in the Statehouse has been to create an environment in Ohio where businesses can grow and thrive so we can help our friends and neighbors get back to work,” said Balderson. “When our local pharmacies came and showed me the costly and burdensome process they have to undergo during audits, I knew we needed to do something to help these family-owned businesses.”
Ohio pharmacies are routinely audited by health plans and insurance companies to check for accuracy and to make certain there has been no fraud, waste, abuse, or clerical errors that may cause accidental overpayments. However, these audits frequently occur with little or no notice to the pharmacy and can be overly burdensome for local, independently owned pharmacies.
“This bill provides fair and uniform oversight for pharmacy audits and ensures this process pinpoints and weeds out actual fraud instead of simply creating unnecessary loopholes without improving the system for Ohioans or our local businesses,” added Balderson.
On average, the cost of per audit to a pharmacy is $2,500 and some Ohio pharmacies indicated that they face 6 of these audits each year.
Senate Bill 258 would make Pharmacy Benefit Managers (PBMs) subject to reasonable audit standards by placing guidelines on when and how audits are conducted. These new standards include:

  • Providing the pharmacy at least 10 days' notice of their intent to audit.
  • Allowing recoupment only if the errors are substantive and not merely typographical or clerical in nature.
  • Limiting the practice of extrapolation under most conditions.
  • Establishing a written appeals process that clearly defines timelines for appealing audit findings.
  • Resubmitting a disputed claim using commercially reasonable methods.

29 other states have already enacted audit reform measures similar to those in Senate Bill 258. The legislation now proceeds to the Ohio House of Representatives for further consideration.

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