Managed Care, PBMs & Pharmacies
Navigating Complexity Across the Benefit and Drug Delivery Chain
Mintz advises managed care organizations, pharmacy benefit managers (PBMs), and pharmacies on the legal, regulatory, and business complexities that define this fast-moving sector. We support clients across the full benefit and drug delivery continuum — including health plans, PBMs, retail and specialty pharmacies, and the vendors that support them — helping them stay compliant, competitive, and ready for what’s next. Whether structuring a new offering, responding to regulatory scrutiny, or executing a strategic transaction, clients count on us for practical guidance rooted in deep industry insight.
ShareOur Approach
We’re not just legal advisors — we’re industry insiders. Our multidisciplinary team brings together health care regulatory, transactional, contracting, and enforcement experience to provide comprehensive counsel across every stage of your operations. We’ve spent decades working with plans, PBMs, pharmacies, and their partners — and regularly engage with CMS, OIG, state Medicaid agencies, insurance departments, and pharmacy boards on their behalf.
Because we understand how these sectors interact — from reimbursement and risk adjustment to pharmacy pricing and formulary strategy — we help clients anticipate change, respond to scrutiny, and lead in a complex regulatory environment. Whether advising on benefit design, DIR reporting, licensing, or bid strategy, we offer more than answers: we offer strategy, foresight, and solutions that move your business forward.
What We Do
We advise clients on a wide range of legal and strategic matters, including:
- Medicare Advantage and Part D bids, contract applications, service area expansions, and related-party disclosures
- Medicaid managed care RFPs, procurement, contracting, and bid protests
- PBM and pharmacy licensure, corporate compliance, and state-specific regulatory issues
- Medical Loss Ratio (MLR) and Direct & Indirect Remuneration (DIR) reporting and dispute resolution
- Risk adjustment audit response (e.g., RADV), documentation strategy, and compliance reviews
- Fraud, waste, and abuse (FWA) program development and federal self-disclosure guidance
- CMS marketing and communications rules, including broker/agent arrangements and incentive programs
- State pharmacy law, pricing transparency requirements, and pharmacy services administrative organizations (PSAOs)
- Strategic mergers, acquisitions, divestitures, and joint ventures involving MA plans, PBMs, and pharmacies
- Private equity investments in managed care and pharmacy services platforms
- Regulatory due diligence, transaction structuring, and change-of-ownership support
- EGWP structuring and CMS contracting for MA plans and PBM clients
- Pharmacy ownership transitions, licensing strategy, and regulatory filings
- Related-party contracting reviews for bid and MLR compliance
- Pharmacy network development, credentialing, and provider compensation models
- PBM contracting, including formulary strategy, rebate aggregation, and transparency requirements
- Value-based care and shared savings arrangements involving plans, PBMs, providers, and pharmacies
- Advanced benefit design — hospital-at-home, telehealth, supplemental benefits, OTC benefits
- Utilization management (UM), prior authorization (PA), and e-PA compliance and delegation
- Wraparound and carve-out contracting strategies across Medicaid and Medicare populations
- Representation in federal and state fraud and abuse investigations, including FCA and AKS matters
- Subpoena response and internal investigations related to DIR, risk adjustment, and formulary design
- Commercial litigation and arbitration involving PBM, rebate, or network disputes
- Bid protests and procurement challenges at the state level
- Defense in qui tam suits and government enforcement actions involving MA, Part D, or Medicaid programs
- We counsel a wide range of organizations across the managed care, PBM, and pharmacy landscape
- National and regional health plans and managed care organizations (MCOs)
- Medicare Advantage Organizations (MAOs) and Part D plan sponsors
- Medicaid managed care and dental plans
- PBMs — independent, integrated, and newly formed platforms
- Retail, specialty, and mail-order pharmacies
- EGWP plan sponsors and PBM partners
- Rebate aggregators and pharmacy networks
- PSAOs, third-party administrators (TPAs), and benefit optimization vendors
- Risk adjustment, utilization management, and supplemental benefit providers
