PBM Contract and Audit Defense Services
With extensive experience navigating the intricacies of Pharmacy Benefit Manager contracts and disputes, we provide strategic counsel for both plan sponsors and pharmacies that helps to mitigate risk and protect the interests of their businesses.
Helping Our Clients Navigate PBM Relationships
As prescription drug costs continue to rise, traditional Pharmacy Benefit Managers have emerged as “middlemen” to process prescription drug claims. While they promise to lower drug spend across the supply chain, PBMs have employed practices to benefit their own financial gain, including spread pricing tactics in drug reimbursements and manufacturer rebates. These practices have significantly contributed to, among other things, increased drug spend of plan sponsors, increased out-of-pocket expense for patients, and low reimbursement rates to pharmacies.
In this increasingly complex landscape with enhanced regulatory attention, engaging with a team of seasoned practitioners in the pharmacy benefits space is critical for plan sponsors and pharmacies to mitigate risks and protect your business. With a Certified Pharmacy Benefits Specialist™ on our team, we have a deep understanding of PBM operations, pricing, plan design, cost-containment strategies, contracts, procurement and pharmacy benefits management. Our PBM defense attorneys are prepared to help clients navigate PBM relationships and disputes through strategic counsel and advisement.
Our Services for Plan Sponsors
Our team advises a broad spectrum of plan sponsors including self-funded plans (employers, labor funds, public sector, and federal), health plans (commercial, Medicare, Medicaid, and exchange plans), and regulated markets (Medicare, Medicaid, and public health exchanges). We work with you to ensure you have a deep understanding of the risks that might arise when contracting with PBMs and help you to protect your members.
Contracts and Disputes
Leveraging our teams’ deep pharmacy benefits knowledge and experience, we help plan sponsors achieve cost savings, transparency, and fairness in their dealings with PBMs. Our line of sight into PBM operations enables plan sponsors to negotiate better terms or explore alternative options to reduce costs.
Our PBM contract services include:
- Representation in contractual negotiations
- Auditing of PBM performance and compliance with contractual and fiduciary obligations
- Educating plan sponsors on contractual rights and relationships with PBMs, including pass-through pricing and manufacturer rebates
- Pursuing legal action against PBMs to enforce contract terms and conditions
- Conducting and guiding Requests for Proposal (RFPs)
- Reviewing and analyzing existing PBM Agreements
- Drafting and negotiating PBM Agreements
- Assistance with CMS reporting and CMS audits
Fiduciary Duty
Without a full understanding of PBM contracts, plan sponsors could be unwittingly contributing to higher costs for members. We help plan sponsors properly manage prescription drug benefits, monitor PBMs’ performance, reduce drug spend, and fulfill their fiduciary duties owed under the Employee Retirement Income Security Act of 1974 (ERISA) and Consolidated Appropriations Act of 2021. When PBMs have engaged in behavior that breaches their contractual obligations and/or fiduciary duties, we ensure our clients understand their legal rights and provide strategic counsel in situations where more aggressive legal action is appropriate.
Plan Sponsor Regulatory and Compliance
As policymakers and regulators continue to focus on PBMs, plan sponsors may find themselves under pressure to demonstrate that they are actively managing their relationships with these intermediaries and protecting their members from unnecessary costs. We advise plan sponsors and employers on compliance with various state and federal laws.
Our Services for Pharmacies
We also provide counsel to a broad cross-section of pharmacies and pharmacy providers – including community retail pharmacies, chain pharmacies, compounding pharmacies, specialty pharmacies, mail order pharmacies, home infusion providers and dispensing physician practices. Our PBM defense attorneys work with you to overcome challenges with PBM audits and contract enforcement.
Audit Defense and Network Disputes
We take a strategic approach to resolving disputes between pharmacies and PBMs, leading to favorable outcomes that preserve pharmacy operations and secure business growth. Our PBM audit defense attorneys are able to anticipate PBM tactics and take actions that not only resolve immediate issues but also mitigate risks and maintain positive relationships with PBMs.
We work with pharmacies to address:
- PBM audits
- Fraud, Waste and Abuse (FWA) investigations
- Network suspensions or terminations
- Reimbursement disputes
- Enrollment denials
- Credentialing and Recredentialing
- Licensing and Registration
State Board of Pharmacy Investigations, Inspections, and Other Related Matters
Our team also advises pharmacies, practitioners, and pharmacy owners with respect to Board of Pharmacy (BOP) matters and other governmental agencies. We have a deep understanding of the legal rights and tools available to pharmacies and work with you proactively to protect your business and licensure. In recent years, we have noticed an increasing trend of collaboration between PBMs and BOPs, which often results in investigations that resemble PBM audits. Disciplinary actions taken by one BOP can trigger similar actions by BOPs in other areas. Moreover, disciplinary measures from a single BOP can prompt PBMs to consider ending their contractual agreements with the affected pharmacy. Therefore, it is crucial for pharmacies and pharmacists to approach their interactions with BOPs with the highest level of seriousness and diligence.
Pharmacy Transactions and Change of Ownership Requirements
Our attorneys provide comprehensive support beyond PBM contract services and audit defense, offering strategic consultation to pharmacies, wholesalers, and manufacturers. We focus on mitigating legal and operational risks while enhancing compliance and profitability. Recognizing the unique nature of transactions within the pharmacy and drug supply chain, we offer specialized expertise to navigate the complexities of these dealings. Our services include representing various entities in pharmacy-related transactions, assisting with corporate formation, due diligence, licensing, change-of-ownership requirements, and credentialing. The intricate elements of pharmacy transactions, such as extensive licensing, regulatory considerations, and the management of PBM contracts, are handled with particularized attention and knowledge.