The first quarter of 2025 has made one thing clear: Pharmacy Benefit Managers (PBMs) have ramped up their enforcement playbook, catching many independent pharmacies off guard.  PBMs aren't just conducting audits - they're laying traps.  They're reaching back to past audit findings, scrutinizing routine business practices, and stretching contractual language to justify aggressive enforcement actions, including network termination. 

If Q1 is any indication of what the rest of the year will bring, pharmacies must act now.  The landscape isn't just shifting - it's accelerating. 

Here's a recap of key PBM enforcement trends we've seen in the first three months of 2025 and what independent pharmacies should be doing now to stay ahead of what's coming. 

PBMs Are Reopening Old Wounds

One of the most troubling developing in Q1 has been PBMs' increased use of past audit findings - resolved or not - as justification for network removal. When PBMs identified discrepancies during audits, they would assess recoupments and move on.  In recent months, PBMs have begun citing audit findings from one or even two years ago as evidence of a broader pattern of non-compliance.  And they're using that pattern to unilaterally suspend pharmacies' adjudication or payment suspension.  Or, in more egregious cases, they have been terminating pharmacies from their networks.  Even when a pharmacy accepted the recoupment - whether under protest or not - PBMs are keeping the matter open in their internal systems and revising them.  

If you have any unresolved audits - especially those where you allowed a recoupment - it's critical to revisit and formally close those matters.  Do not assume the issue is behind you just because the money has already been withheld.

Geographic Scrutiny is still in Play

Another major trend in Q1 has been PBMs cracking down on dispensing practices tied to shipping, delivery, and patient geography.  Pharmacies servicing patients across state lines - especially in non-bordering or distant states - have found themselves flagged, audited, and in some cases, terminated.  PBMs are also zeroing in on prescriber proximity. When prescribers are located far from both the patient and the dispensing pharmacy, PBMs are alleging that the relationships may not be legitimate—or that the pharmacy is engaging in “steering” or acting like an unlicensed mail-order operation.  

If your pharmacy ships medications or services a wide geographic footprint, ensure you have documentation proving patient choice and compliance with each state’s licensure requirements. Review prescriber-patient-pharmacy proximity and flag any outliers for internal review.

Copay Assistance and Coupon Programs Triggering Audit Findings

PBMs spent Q1 aggressively auditing pharmacies over copay collection practices, focusing particularly on pharmacies that handle high-cost medications, such as GLP-1s and specialty drugs. Common allegations include, among other things, (i) routine copay waivers without documented financial hardship; (ii) improper use of discount cards or coupon programs; (iii) accepting manufacturer copay assistance in violation of contract terms; and (iv) delegation of copayment collection to third-parties.  In many cases, PBMs are treating these actions not as simple policy breaches, but as potential fraud. 

You should review how your pharmacy collects copays, especially on high-cost claims. Make sure any copay discounts are documented and justified. If you use manufacturer copay assistance or third-party coupon platforms, verify that doing so complies with your PBM contracts and that records are maintained.

PBMs Expanding Definition of Non-Compliance

PBMs have quietly updated their provider manuals over the last few months, using vague and ever-broadening terms like “abusive billing,” “material breach,” or “pattern of concern.” These terms have become the basis for more aggressive audit findings and terminations.  Do not assume that because you followed state and federal law, your contract is safe. Review your provider manual regularly and consult counsel when ambiguities arise.  

Expect More FWA Referrals and Less Due Process

Q1 has shown that PBMs are increasingly blurring the line between audits and FWA investigations. What begins as a standard invoice audit or documentation request can quickly turn into a formal FWA referral—often with little notice.  This is particularly dangerous because FWA referrals often result in immediate network termination with no meaningful right to cure or appeal.  In some cases, PBMs are even referring matters to state Boards of Pharmacy or other regulatory agencies, creating additional exposure for pharmacies already under pressure. 

What Pharmacies Should Do Now

With three months already in the books, independent pharmacies can’t afford to wait and see. The trends are already here, and Q2 will likely bring more of the same. Here’s what you should do now:

Audit your own audits: Review past audit findings, even if you allowed recoupment. Consider closing the loop and pushing for written resolution to prevent future use against you.
Document everything: From PA assistance to copay adjustments, if you’re not writing it down, you’re vulnerable.
Monitor delivery and geography: Be able to explain why you’re servicing patients outside your region and maintain licensure records.
Review your PBM agreements: Especially the updated provider manuals. What was acceptable in 2023 or 2024 might now be considered a breach.
Get legal support early: Don’t wait until you’re facing termination. Engage experienced counsel as soon as an audit notice lands in your inbox.

Final Thought

If the first quarter of 2025 has taught us anything, it’s this: PBMs are not just tightening enforcement—they’re rewriting the rules mid-game. Independent pharmacies must respond with vigilance, documentation, and a proactive compliance posture.  The rest of the year is only going to get tougher. Stay alert, stay prepared, and above all, protect your network participation like your business depends on it—because it does.