Theresa has extensive experience advising clients on all aspects of the pharmaceutical supply chain. Her practice involves advising industry stakeholders on a range of business, legal, transactional, and compliance matters. Theresa combines her multilayered industry knowledge with a deep understanding of applicable federal and state legal frameworks, in particular federal and state fraud and abuse laws. She provides clients with strategic counseling and creative business modeling that considers legal restrictions and regulatory risk in light of innovation and business goals.
PBMs and Plans
Theresa applies her comprehensive knowledge of the PBM industry, the legal landscape, and relevant policy initiatives to provide insightful and strategic counsel to plans and PBMs on all aspects of their operations. She regularly assists PBMs and plans in evaluating and structuring innovative strategic alliances, payment structures, and collaborations. She has extensive experience in:
- PBM Service Agreements from both the PBM and plan perspective
- Rebate Contracting, including value-based and outcomes-based rebating arrangements
- Rebate Aggregator and Formulary Service Arrangements
- Pharmacy Network Contracting
- Workers Compensation PBMs
Specialty Pharmacies
Theresa counsels independent and plan/PBM-affiliated specialty pharmacies on regulatory, operational, and contracting matters. She assists specialty pharmacies with:
- Drug Purchase and Service Arrangements
- Fraud and abuse risks in connection with arrangements with pharmaceutical manufacturers
- Payor Relationships
- Wholesaler Arrangements
- Prescription Drug Adherence Programs
- State Pharmacy Law Requirements
- Medicare Part D Regulatory Requirements
Drug Distribution and Procurement
Theresa knows that understanding the interaction among all entities in the pharmaceutical supply chain is critical to providing practical, business oriented advice and services. In addition to plans, PBMs, and pharmacies, she advises a variety of different stakeholders in the pharmaceutical supply chain, including:
- Providers negotiating national drug supply and procurement agreements
- Group Purchasing Organizations
- Reimbursement HUBs
- Co-pay and Coupon Program Administrators
Innovative and Direct-to-Consumer Drug Discount Programs
Theresa advises entrepreneurial health care providers on innovative platforms for the delivery of prescription drugs, pharmacy benefits, and drug discounts, including.
- Prescription Drug Discount Cards
- Direct-to-Consumer Discount Offerings
- Disruptor and alternative model PBM services
Digital Pharmacy Services
Theresa advises telehealth technology developers, telehealth providers, and pharmacies on federal and state regulatory schemes applicable to telehealth participation in the pharmaceutical supply chain and the provision of digital pharmacy services. She counsels clients on fraud and abuse requirements, provides contracting support, and assists with structural considerations such as state corporate practice of medicine (CPOM) requirements.
M&A and Transactional Matters
Theresa regularly represents clients in connection with their investment in the pharmaceutical supply chain. She uses her extensive knowledge of the pharmaceutical supply chain to advise clients investing in the industry on structural considerations, corporate matters, regulatory requirements and compliance risks, and business challenges and opportunities. Theresa assists clients in both M&A transactions and private equity investments and has deep experience in contracting matters, complex due diligence reviews, fraud and abuse risks, licensing, and regulatory and change of ownership (CHOW) filings.
COVID-19 Matters
Most recently, Theresa has advised clients on the impact of COVID-19 on the pharmaceutical supply chain, including its impact on state pharmacy law requirements, Medicare Part D benefit design requirements, and contracting arrangements.
Theresa is a frequent author and speaker on regulatory and policy issues affecting pharmacy benefits and the pharmaceutical supply chain and a regular contributor to the firm’s Health care Viewpoints.
Experience
- Represented Cigna as health regulatory counsel in its acquisition of Express Scripts.
- Represented Catamaran (f/k/a CatalystRx) in the structuring and negotiation of its PBM services arrangement with CIGNA.
- Represented national worker’s compensation PBM in connection with multiple worker’s compensation PBM acquisitions.
- Represented a national specialty pharmacy provider in connection with an internal compliance audit and investigation and response to government investigation.
- Advised national pharmacy chain in multiple specialty pharmacy and long-term care pharmacy acquisitions.
- Represented SingleCare, a discount medical and pharmacy card operator (“DMPO”), in its contracting with pharmacies, providers and other vendors.
- Served as regulatory counsel to a consortium of investors led by TPG Capital and Welsh, Carson, Anderson & Stowe in their $4.1 billion acquisition of Kindred Healthcare, Inc. (NYSE:KND). The transaction was recognized by The Deal as the 2018 Private Equity Deal of the Year.
- Advised a global health care company on a variety of issues in connection with its acquisition of several health plans and provider groups, including health care regulatory due diligence, health care regulatory advice regarding transaction structure and strategy, and preparation of regulatory notices and other filings.
- Advised national pharmacy chain in connection with government agency arrangement to provide accessible COVID-19 testing.
viewpoints
PBM Policy and Legislative Update — Fall 2024
November 22, 2024 | Blog | By Rachel A. Alexander, Tara E. Dwyer, Theresa Carnegie, Bridgette Keller, Madison Castle, David Gilboa, Xavier Hardy, Samantha Hawkins, Stephnie John, Lauren Moldawer, Alison H. Peters, Abdie Santiago, Hassan Shaikh, Sophia Temis
Building upon prior issues and summarizing activity from July through September, the Fall 2024 PBM Update highlights federal legislative activity and oversight, state legislative activity and oversight, and other noteworthy events and trends affecting the PBM industry.
CMS 2026 IRA Price Negotiations Results Likely to Create Upstream and Downstream Effects
August 20, 2024 | Blog | By Rachel A. Alexander, Theresa Carnegie, Xavier Hardy, Alison H. Peters, Madison Castle
On August 15, 2024, CMS announced the results of the first round of the negotiated prices between CMS and participating drug manufacturers for the 10 selected drugs under the Inflation Reduction Act’s (IRA) Medicare Drug Price Negotiation Program (MPN or Program). In all, reactions to the MPN results varied: Reuters reported that executives from four of the manufacturers selected in the first round of negotiations stated that they do not expect the negotiated prices to significantly impact their businesses; meanwhile, in its press release announcing the maximum fair prices (MFPs), CMS touted an estimated $1.5 billion in Medicare prescription drug out-of-pocket cost savings for Medicare beneficiaries when the negotiated prices go into effect in 2026.
PBM Policy and Legislative Update — Summer 2024
July 31, 2024 | Blog | By Theresa Carnegie, Tara E. Dwyer, Rachel A. Alexander, Bridgette Keller, Madison Castle, David Gilboa, Xavier Hardy, Samantha Hawkins, Stephnie John, Pat Ouellette, Alison H. Peters, Abdie Santiago, Hassan Shaikh, Sophia Temis
Mintz IRA Update — Third Edition: Q2 2024
July 15, 2024 | Blog | By Rachel A. Alexander, Theresa Carnegie, Madison Castle, Mitchell Clough, Tara E. Dwyer, David Gilboa, Xavier Hardy, Samantha Hawkins, Stephnie John, Bridgette Keller, Lauren Moldawer, Abdie Santiago, Hassan Shaikh
In ‘Third Edition: Q2 2024’ of the Mintz IRA Update, we cover updates to the Medicare Drug Price Negotiation Program being considered by CMS, developments in litigation challenging the program, the consequences and costs of redesigning the Part D program, opposition to the use of march-in rights to lower drug prices, and the growing use of state prescription drug affordability boards.
PBM Update: Special Edition - FTC 6(b) Interim Staff Report and Activity
July 12, 2024 | Alert | By Rachel A. Alexander, Tara E. Dwyer, Theresa Carnegie, Joseph Miller , Bridgette Keller, Samantha Hawkins, Hassan Shaikh, Payton Thornton
On July 9, 2024, the Federal Trade Commission (FTC) Office of Policy Planning released an Interim Staff Report titled Pharmacy Benefit Managers: The Powerful Middlemen Inflating Drug Costs and Squeezing Main Street Pharmacies. The Interim Staff Report reflects the FTC’s work since it began its 6(b) study of PBMs in June 2022. Mintz’s Health and Antitrust teams actively monitor federal and state regulatory and legislative developments in the PBM space, including those from the FTC. In this Special Edition of the PBM Policy and Legislative Update, the Mintz Health team partnered with our Antitrust colleagues to analyze the Interim Staff Report including Commissioner Melissa Holyoak’s dissenting statement. We also highlight upcoming Congressional testimony by CEOs of the three largest PBMs, as well as media reports of a forthcoming FTC action related to PBM insulin rebate practices.
PBM Policy and Legislative Update — Winter 2024
May 2, 2024 | Blog | By Theresa Carnegie, Tara E. Dwyer, Rachel A. Alexander, Bridgette Keller, Madison Castle, David Gilboa, Xavier Hardy, Abdie Santiago, Hassan Shaikh, Sophia Temis
Mintz is pleased to present its quarterly publication, PBM Policy and Legislative Update. This edition builds upon prior issues and summarizes activity from October through December 2023 that affects the PBM industry and will specifically highlight (i) federal legislative and enforcement updates, (ii) state legislative updates and litigation, (iii) other industry news, and (iv) Inflation Reduction Act (IRA) updates.
Mintz IRA Update — Second Edition: Q1 2024
February 21, 2024 | Blog | By Rachel A. Alexander, Theresa Carnegie, Tara E. Dwyer, Madison Castle, Mitchell Clough, Xavier Hardy, Stephnie John, Bridgette Keller, Abdie Santiago, Hassan Shaikh
In this edition of the Mintz IRA Update, we cover the status of the negotiations underway between CMS and manufacturers pursuant to the Medicare Drug Price Negotiation Program and current legal challenges to the program, other drug pricing–related IRA initiatives, the IRA’s small biotech exemption, implications associated with removing the average manufacturer price cap on Medicaid rebates, and the Biden administration’s proposed draft guidance on patent “march-in” rights.
HHS Court Filings Indicate that Agency Intends to Preserve Copay Accumulators
December 4, 2023 | Blog | By Theresa Carnegie, Xavier Hardy, David Gilboa
As we wrote about in our prior blog post, on September 29, 2023, John D. Bates of the U.S. District Court for the District of Columbia struck down a federal rule that permitted health plans and pharmacy benefit managers (PBMs) to exclude drug manufacturer copayment (copay) assistance from a patient’s cost sharing limits. In two separate filings this week, HHS signaled that it intends to support the continued use of copay accumulator programs as the industry has been using them since 2021.
Court Strikes Down HHS Rule on Copay Accumulators: Implications for Health Plans and PBMs
October 9, 2023 | Blog | By Theresa Carnegie, Xavier Hardy, David Gilboa
In a significant development with far-reaching implications for health plans and pharmacy benefit managers (PBMs), Justice John D. Bates of the U.S. District Court for the District of Columbia has recently struck down a federal rule that allowed health plans to use copay accumulator programs to exclude drug manufacturer copay assistance from a patient’s out-of-pocket costs. This ruling has significant implications for the way health plans and PBMs operate and interact with patients and copay assistance programs.
Mintz IRA Update — Inaugural Edition
September 20, 2023 | Blog | By Theresa Carnegie, Tara E. Dwyer, Mitchell Clough, Xavier Hardy, Stephnie John, Bridgette Keller, Lauren Moldawer, Pat Ouellette, Hassan Shaikh
Mintz’s PBM & Pharmacy practice is proud to present the Mintz IRA Update, a regular publication that delves into the spectrum of developments under the Inflation Reduction Act of 2022 (“IRA”) impacting the health care industry.
News & Press
Despite Vaccine Spotlight, RFK Jr. A Health Policy 'Unknown'
November 15, 2024
Member Theresa Carnegie was quoted by Law360 in an article about the unknowns of Robert F. Kennedy Jr.’s health policies following his nomination by President-elect Trump to head the Department of Health and Human Services.
Mintz announced today that 42 of its practices and 83 of its attorneys earned recognition in the 2024 edition of Chambers USA, a guide to the country’s leading law firms. Of those included in the guide, 18 attorneys and seven practice areas were awarded Chambers’ highest ranking, Band 1. The firm obtained new listings in three practice areas and 10 of its lawyers were recognized for the first time.
Healthy Returns: What’s Next In The Legal Fight Over Medicare Drug Price Negotiations
March 13, 2024
CNBC spoke with Member Theresa Carnegie on the legal battle over Medicare drug price negotiations. Drug makers argue that such negotiations would force them to sell medicine at significant discounts, violating their due process under the Fifth Amendment. Theresa commented on the government’s initial victories and their potential impact on remaining legal challenges.
Bloomberg Law spoke to Member Theresa Carnegie in an article discussing how four leading drugmakers are challenging the Medicare Drug Price Negotiation Program in federal court.
HHS Pushes Back on Accumulator Ruling, Prompting Wait-and-See Situation
December 21, 2023
MMIT quoted a recent article written by Mintz attorneys Theresa Carnegie, Xavier Hardy, and David Gilboa in a story discussing the US district court ruling that overturned a federal rule allowing health plans to exclude copayment assistance from members’ out-of-pocket costs. The article notes the Department of Health and Human Services’ current stance of refraining from immediate action.
4 Pharma Industry Arguments Against CMS Drug Pricing Plan
September 29, 2023
Theresa Carnegie, Lauren Moldawer, and Hassan Shaikh co-authored an article published by Law360 on the Inflation Reduction Act's Medicare drug pricing negotiation program.
Big Pharma’s Fight Over Medicare Drug Price Negotiations Faces Multiple Challenges
September 11, 2023
Health Payer Specialist spoke to Member Theresa Carnegie about implications resulting from the Biden administration’s plan to place drugs in the Medicare program under price negotiation.
Medicare’s 10-Drug List: The Industry Reacts
August 30, 2023
Theresa Carnegie's comments were featured in a PharmaVoice newsletter article analyzing the Biden administration's announcement of the first 10 drugs up for Medicare price negotiations.
BOSTON –Mintz announced today that 39 of its practices and 81 of its attorneys earned recognition in the 2023 edition of Chambers USA, a guide to the country’s leading law firms.
Five Mintz Attorneys Named 2020 BTI Client Service All-Stars
December 11, 2020
Trump Unveils Disputed, Long-Shot Drug Rules Upending System
November 23, 2020
Mintz Attorney Theresa C. Carnegie and ML Strategies Vice President Rodney L. Whitlock to Speak at Fifth Annual Pharmacy Benefit Oversight & Compliance Conference
November 07, 2016
Events & Speaking
Examining the Impact of COVID-19 on Pharmacy Benefits and the Pharmaceutical Supply Chain
American Health Law Association Annual Meeting
Online Event
4th Annual Mintz /ML Strategies Pharmacy & Pharmaceutical Industry Summit
Mintz and ML Strategies
Boston, MA
3rd Annual Mintz /ML Strategies Pharmacy & Pharmaceutical Industry Summit
Mintz and ML Strategies
Boston, MA
3rd Annual Mintz /ML Strategies Pharmacy & Pharmaceutical Industry Summit
Mintz and ML Strategies
Boston, MA
Pharmacy Benefits and Pharmaceuticals: State of the Industry Update
AHLA
Marriott Chicago Downtown, Magnificent Mile, Chicago, IL
4th Annual Pharmacy Benefit Oversight & Compliance Conference
CBI
16770 North Perimeter Drive Scottsdale, AZ
Recognition & Awards
BTI Consulting Group: Client Service All-Star (2020)
Chambers USA: District of Columbia (Up and Coming) – Healthcare (2014, 2015); Chambers USA: District of Columbia – Healthcare (2023, 2024)
Recognized by The Legal 500 United States for Healthcare: Service Providers (2024)
Nightingale’s Healthcare News: Outstanding Young Healthcare Lawyers (2005)
Phi Beta Kappa