§ 4436 Pharmacy Audit Clinical Standards

(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. (Added by Stats. 2012, Ch. 706, Sec. 1. (SB 1195) Effective January 1, 2013.)