Pharmacy Audit Integrity Act Complaint Form

Contracting Agent/PSAO Name (If none, N/A)

Was Contracting Agent/PSAO Notified of Audit

Yes

Unsure

N/A

Date Notification Received by Pharmacy

The date Pharmacy received notification, not the date on the notification letter

mm/dd/yyyy

Date of Pharmacy's Initial Audit Response

The date Pharmacy emails, faxes, mails, etc. response to the PBM, not the Due Date provided by PBM

mm/dd/yyyy

Date of Preliminary Report to Pharmacy

The date Pharmacy received the Preliminary Report, may match the date on the letter

mm/dd/yyyy

Date of Pharmacy's Second Response

The date Pharmacy submits follow-up documentation in response to the Preliminary Report

mm/dd/yyyy

Date of Final Report to Pharmacy

The date Pharmacy received the Final Report, may match date of letter

mm/dd/yyyy

Date of Audit Appeal Submitted

The date the Pharmacy (or PSAO, on behalf of the Pharmacy) submits the appeal documentation to the PBM

mm/dd/yyyy

Date of Audit Appeal Results

The date the Pharmacy receives the results of the appeals from the PBM

mm/dd/yyyy

File Upload

Please provide ALL available audit related documentation received and submitted by the Pharmacy (Including invoices)

Drop your files here