Investor Presentaiton
Oregon's PBM structure and current statute limit patient protections for prescriptions
A preferred drug list is a list of prescription drugs covered under a health plan. Health plans use
preferred drug lists to negotiate drug rebates and encourage providers to prescribe those medications.
Uniform preferred drug lists support administrative simplicity for providers and consistent drug
coverage for patients.
Currently, Oregon has 16 different CCOS with multiple preferred drug lists. Having multiple preferred
drug lists in Medicaid creates challenges for patients, providers, and OHA. If people move to an area
with a different CCO, the prescription drug they previously took may or may not be on the new CCO's
preferred drug list. If a person is prescribed a medication not on the list, extra steps need to be taken
before the individual can obtain their prescription.
For example, a person who lives in Coos Bay takes a blood pressure medication that works well for
them and was prescribed by their doctor. The person moved to Clackamas and now has a new CCO,
PBM, and preferred drug list. The original blood pressure medication might not be covered on the new
list. If this happens, the person might have to try new medications first, that may not work as well, or
the provider and patient will have to start the prior authorization process, which can be burdensome to
both patients and providers.1
1920
PBMs will often move drugs on and off their preferred drug list depending on research and market
conditions. Frequent changes to covered drugs are burdensome, especially when changes are not
uniform across the state. In 2018, the Oregon Health Policy Board recommended alignment of the
preferred drug lists for FFS and CCOs to the Legislature but it was never implemented. Figure 11 shows
many other states have adopted this leading practice in their Medicaid programs. To bring consistency
to patients, Oregon's Legislature should mandate a uniform preferred drug list for Medicaid. A standard
prior authorization process would be easier to implement under a uniform preferred drug list.
19 Prior authorization requires prescribers to receive pre-approval for prescribing a particular drug for that medication to qualify
for coverage under the terms of the pharmacy benefit plan. Prior authorization processes can differ among CCOS.
20 OAR 410-141-3850 requires CCOS to provide continued access to services when a Medicaid recipient moves from another CCO.
This rule does not apply to a Medicaid recipient who has a gap in coverage following disenrollment due to failure to respond to
mail from OHA that was sent to the recipient's prior address. Under the existing model, there remains different access to
prescription drugs for Medicaid recipients depending based on where they live.
Oregon Secretary of State Report 2023-25 | August 2023 | page 16View entire presentation