Investor Presentaiton
To illustrate why it is important to capture pricing information from PBMS, we have included a table
highlighting how pricing can vary dramatically between PBMs and the pharmacies that dispense the
drugs. For Trulicity, a medication used for the treatment of type 2 diabetes, our audit work has
identified Medicaid reimbursement rates resulted in estimated pharmacy losses of $58.82 per
prescription dispensed to estimated pharmacy profits of $53.29 per prescription dispensed.
Figure 3: Pharmacy reimbursement rates are inconsistent between PBMs in Medicaid
Average Oregon
acquisition cost
Number of
Drug
NDC
Month PBM
units
Estimated pharmacy
profit/loss
Prescription 1 Trulicity 2143380
Prescription 2 Trulicity 2143380
Prescription 3 Trulicity 2143380
Prescription 4 Trulicity 2143380
Prescription 5 Trulicity
Apr-21
PBM1
2
$404.31
($58.82)
Apr-21 PBM2
2
$404.31
($16.58)
Apr-21 PBM3
2
$404.31
$9.57
Apr-21 PBM4
2143380 Apr-21 PBM5
2
$404.31
$19.50
2
$404.31
$53.29
Source: Preliminary auditor analysis of OHA and PBM Medicaid data
Our audit work is focused on PBMs within the Medicaid program and not those regulated by the
Department of Consumer and Business Services (DCBS). It is important to note current statutes define
PBMs as an organization that contracts with pharmacies on behalf of an insurer offering a health
benefit plan, a third-party administrator, or the Oregon Prescription Drug Program established in ORS
414.312.3 DCBS does not consider Medicaid PBMs to fall under that definition and are therefore not
subject to most statutory requirements. As a result, Medicaid PBMs are not regulated by DCBS, and
statutory changes are required if the legislative intent is to capture pricing information from all PBMs
operating in the state. Medicaid serves one in three people in Oregon and the current limited statutory
definition provides an incomplete picture of all PBMs operating in the state.
When considering new legislation, it is important to consider both quantitative and qualitative impacts
to enrollees, the program, and key stakeholders. We suggest reaching out to DCBS and OHA and other
stakeholders while drafting legislation to discuss the impacts to the programs they administer. We
hope you find value in this communication and would be happy to answer any questions you have.
We plan on issuing our audit report later this year, which will provide additional details around leading
practices as well as risk areas and important background information. If you have any questions, please
contact Audit Manager lan Green at (971) 239-7934.
Sincerely,
Kip Memmott
Director, Audits Division
Oregon Secretary of State
CC: James Schroeder, Director, Oregon Health Authority
CC: Representative Nancy Nathanson; Representative Rob Nosse; Senator Elizabeth Steiner
CC: Chairs of the Senate Committee on Health Care; Joint Committee on Legislative Audits
CC: Andrea Cooper, Governor's Office
3 See ORS 735.530 for the full definition of a pharmacy benefit manager.
Oregon Secretary of State | February 2023 | page 3View entire presentation