Investor Presentaiton
are not contractually required on all amendments, nor have they been done on subsequent
amendments. OHA should require CCOs to submit all contracts and amendments with PBMs for review.
OHA also requires CCOs to complete a yearly market check, which is a comparison of PBM pricing with
the pricing of other comparable PBMS in the market. The intent of this check is to ensure CCOS
understand the need to hold PBMs accountable and to monitor for possible improvement. Data and
analysis from this report is presented to OHA at a summary level, but OHA does not review the
content, due to OPDP staff having a conflict of interest. Not monitoring this control leaves OHA with no
way of knowing if it is effective.
CCOs using a pay-for-performance contract must submit a quarterly report detailing administrative
and dispensing fees, number of claims, and amounts shared between the PBM and CCO, among other
data. OHA staff evaluate the information and send a summary letter to the CCOs and OHA
management for review. OHA intends for this review to identify whether generated PBM profits are
commensurate with the services provided; however, OHA has not required any CCO to act, even when
the evaluation shows the CCO is paying more than the market comparator.
Given the size and complexity of the Medicaid program, it is unreasonable to expect every contract
provision will be monitored in detail. However, for high-risk areas, OHA should focus resources to
provide effective monitoring tools and processes. This includes enforcing compliance with well-defined
escalation steps. Monitoring tools and their results should be evaluated on an ongoing basis and
feedback should be incorporated into the contracting process, which will help give reasonable
assurance CCOs and PBMS are complying.
Billions of dollars are spent on Medicaid. It is important the state take steps to ensure the program is
run efficiently and effectively to better serve people in Oregon. The current structure lacks
transparency and is too complex to efficiently measure value. The State should change the current
model and enact legislation that focuses on patient protections, pharmacy protections, and increasing
transparency in the prescription drug supply chain. Making these changes will help ensure the Medicaid
program is getting good value for pharmacy benefits, people have access to the same medications, and
Oregonians have access to community pharmacies.
Oregon Secretary of State Report 2023-25 | August 2023 | page 31View entire presentation