- Pharmacy Benefit Manager (PBM) Contracting
- Section 111 Insurer Reporting and MSP Reimbursement
Pharmacy Benefit Manager (PBM) Contracting
Wiley Rein routinely represents health plans in their procurement of and contracting with pharmacy benefit managers (PBMs) for Mail, Retail and Specialty drug services in connection with commercial and government programs. The PBM engagements for which we typically are retained often involve health plans with annual drug spend in the billions (e.g., $4 billion in annual drug spend for one of our clients; $8 billion for another).
PBM prescription drug pricing mechanics are extremely complex, constantly evolving and often proposed in a convoluted way. We are highly skilled and experienced at mapping the financial and operational concepts and pricing mechanics into clear, concise, enforceable contract terms that maximize health plans’ leverage, incentivize optimal operational performance, and anticipate potential market fluctuations.
We have prepared contracts for an integrated Retail and Mail program, and contracts to support programs where the Retail, Mail and Specialty functions are segregated. We also have experience drafting contract terms to support numerous pricing strategies including both transparent pricing (both on the Retail and Mail side) and traditional pricing models. We have specific experience drafting provisions addressing various network configurations and corollary pricing, e.g., broad networks, narrow networks, 90-day networks, mail order pharmacy networks. Critically, the various contract provisions we have drafted have weathered negotiation with national top-tier PBMs and are working to our clients’ advantages in contracts today. Our years of experience drafting creative, complex PBM deals means that we can be nimble and draw on a wealth of experiences in capturing the nuances of the most intricate of arrangements.
We have negotiated with many PBMs and have no conflicts with the major players in this arena, including CVS Caremark (CVS Health), ESI (including the former Medco), and Prime Therapeutics.