PBM, PSAO, & Plan Sponsor Support

Protecting Pharmacies in a Complex and Opaque Environment

Pharmacies today face growing challenges in navigating the contracts, audits, and shifting expectations imposed by Pharmacy Benefit Managers (PBMs), Pharmacy Services Administrative Organizations (PSAOs), and Plan Sponsors. Getting legal PBM, PSAO, & plan sponsor support is crucial for enrollment support, navigating contracts, and managing these complex pharmacy business relationships.

From enrollment barriers and reimbursement clawbacks to aggressive audit practices and legal threats, the financial and operational pressure on pharmacies has never been greater.

Why Choose Us at Boesen & Snow Law

PBM, PSAO, and plan sponsor relationships are often unbalanced, but it’s important to know that your pharmacy has rights. At Boesen & Snow Law, our legal team has a deep knowledge of pharmacy operations, along with decades of experience in managed care, payer policy, and regulatory enforcement. We don’t just help you stay compliant—we can advocate for your business’s interests while dealing with industry giants.

At Boesen & Snow Law, we can provide comprehensive legal and strategic support for your pharmacy. Our team can represent you, whether you are an independent, specialty, or compounding pharmacy. We can help your company manage and push back against unfair PBM, PSAO, and plan sponsor practices.

Our firm understands the complexity of this space and can protect your rights. We can help your business remain compliant so that your operations stay profitable.

Our Services

At Boesen & Snow Law, we can assist with several aspects of the complex relationship between your pharmacy, PBMs, PSAOs, and plan sponsors, such as:

PBM and PSAO Enrollment Support

We assist pharmacies with navigating the burdensome credentialing and enrollment process, including by:

• Reviewing and negotiating PBM and PSAO agreements
• Preparing and submitting enrollment and credentialing documents
• Responding to delays, denials, or unreasonable requests

Clawbacks, True-Ups and Effective Rate Disputes

We provide legal counsel and analysis for financial recoveries and reconciliations, including:

• Challenging “true-up” calculations and effective rate shortfalls
• Addressing retroactive DIR fee clawbacks
• Identifying potential contract breaches or financial inconsistencies
• Advising on plan sponsor reconciliation practices

PBM and PSAO Compliance Counseling

We show pharmacies how to meet operational and contractual compliance requirements. There are several aspects to ensuring PSAO/PBM compliance that our firm can help with, including:

• Reviewing policies for audit and network compliance
• Advising on specialty and compounding billing and documentation standards
• Mitigating risk related to network participation and plan sponsor oversight
• Providing strategic insight on contract performance metrics

Cease-and-Desist Letters and Enforcement Response

Whether your pharmacy receives a cease-and-desist letter—or needs to send one—we offer fast, strategic guidance to protect your interests:

• Responding to cease-and-desist letters from pharmaceutical manufacturers, PBMs, competitors, or third parties
• Assessing legal exposure and crafting appropriate responses
• Drafting cease-and-desist letters to stop unfair business practices, including defamation, interference, or misleading claims
• Addressing legal threats and working to resolve disputes before litigation escalates

Specialty Pharmacy Proposals and Network Participation

We help pharmacies pursue opportunities in exclusive or limited distribution networks, including:

• Drafting and submitting specialty pharmacy participation proposals
• Advising on URAC, ACHC, or other accreditation requirements
• Preparing for site visits, data requests, and operational readiness
• Structuring compliance programs to meet payer expectations

Who We Help

We support a wide variety of pharmacy companies, including:

• Independent and community pharmacies
• Compounding and specialty pharmacies
• Mail-order and long-term care pharmacies
• 340B contract pharmacies
• Telepharmacy and multi-state operators

The relationships between PBMs, PSAOs, and plan sponsors are often unbalanced, but your pharmacy has rights that you can protect. There were 1,362 adverse actions taken against pharmacists in 2024, and nearly 1,200 of those were against state licensure or certification. Adverse actions can impact your finances, reputation, and long-term health as a company.

Federal Regulation Compliance

The Food and Drug Administration (FDA) and Drug Enforcement Administration (DEA) also have numerous regulations for your pharmacy business that must be followed.

Our PharmaFortifty™ FDA Inspection and DEA Audit legal service can review your company’s compliance with these agency regulations. Our team can examine the risks to your pharmacy and provide you with actionable information to prepare for an inspection or audit.

FAQs

Q: How Does a PSAO Work?

A: A pharmacy services administrative organization (PSAO) provides support for independent pharmacies when dealing with pharmacy benefit managers (PBMs). This includes administrative tasks like evaluating contracts between the PBM and the pharmacy. PSAOs are paid by the pharmacy at a fixed fee. Unlike PBMs, PSAOs do not benefit from high drug costs and low reimbursement fees that harm independent pharmacies.

Q: What Does PBM Mean for Insurance?

A: PBMs, or pharmacy benefit managers, are companies that are the go-between of insurance companies, pharmacies, and drug manufacturers. PBMs impact the cost of prescription drugs significantly and control a lot of the market. Insurance costs are then affected by the cost of the prescription drug, which affects both pharmacies and consumers.

Q: What Is the Difference Between PBMs and PSAOs?

A: The difference between PBMs and PSAOs is that PSAOs provide an additional buffer between PBMs and pharmacies. PBMs negotiate prices with drug manufacturers on behalf of pharmacies, while PSAOs offer administrative support for pharmacies when negotiating with PBMs. While pharmacies can deal directly with PBMs, it can be much harder for smaller and independent pharmacies. PSAOs can help pharmacies negotiate fairer contracts and compete.

Q: What Is a Prescription Benefit Plan Sponsor?

A: A prescription benefit plan sponsor provides pharmacy benefits for those that enroll in it. Plan sponsors include insurers, car organizations, self-funded employers, and governmental agencies.

These parties are responsible for reimbursing PBMs when an enrolled member files a claim with the plan sponsor. This often results in PBMs increasing costs to require higher reimbursement to make themselves more money. This also harms both patients and pharmacies.

Contact Boesen & Snow Law Today

Navigating PBMs, PSAOs, or plan sponsor disputes can be challenging. Whether you’re enrolling, responding to clawbacks, or defending your business—we can help. You don’t have to face these complex issues alone.

Contact us today to arrange a consultation.