Investor Presentaiton
August 16, 2023
Page 3 of 4
Agree or Disagree
with
Recommendation
Agree
Target date to
complete
implementation
activities
01/01/2025
Name and phone number of
specific point of contact for
implementation
David Inbody
Narrative for Recommendation 1
OHA conducts an annual CCO contract restatement process. These recommended
considerations can be included in the 2025 restatement, which will begin in February 2024.
The specific considerations identified are partially represented in the existing CCO
contract.
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Yearly independent audit - Currently a subcontractor performance audit is required
for all high-risk subcontractors, which would include PBMs. The audits are
conducted by CCOs. In addition, an annual PBM market check is conducted by a
third party on behalf of the CCOs, for those not using OPDP. The contract could be
changed to include an independent audit for PBMs; this would incur additional costs
for all CCOS.
Incorporate monitoring results into contracting process – The addition of Quality
Assurance staff with the background and experience to enable contract oversight
without the appearance of conflict of interest.
Update CCO contract to apply review requirements to all CCO-PBM amendments
or contract renewals. Currently, this requirement only applies to pay-for-
performance PBM subcontracts. This could be changed as part of the next contract
restatement process to apply to all CCO-PBM amendments and contract renewals.
OHA's CCO PBM readiness review includes a market check requirement, which could be
expanded to include an audit of the PBM annually. The third-party nature of this market
check requirement along with an annual audit would indeed give more assurances to OHA
and better position CCOs to oversee their PBMs' behavior. As noted in the report, CCOS
are permitted to utilize OPDP/ArrayRx as their PBM; only one CCO currently elected to
utilize this option. It is important to note that OPDP/Array Rx do perform a third-party review
and market check for all programs participating in interstate cooperative agreement.
Additionally, OPDP/Array Rx conducts quarterly sample audits to ensure claim submission
and payment accuracy for a diverse subset of claims processed for our participating
programs. Annually, ArrayRx completes an audit representing in excess of 50% of its total
claims. This audit assesses the accuracy of 100% of claims that are processed by our
PBM for these programs (as opposed to audits that are conducted in quarterly PBM
audits). The most recent audit results showed that OPDP/ArrayRx PBM had a 99.99%
accuracy rate.
We agree that all subsequent contract amendments between PBMs and CCOS should be
subject to OHA review and approval. This can be in place for the 2025 contract. OHA also
agrees that PBM contracts should be pure pass-through contracts moving forward and will
change the PBM readiness review process to reflect this. To successfully address the
additional analytics and oversight necessary, it would be helpful to find a path to effectively
resource OHA. A recent legal settlement between Oregon and a PBM highlights the need
to have a dedicated resource that can assist with audits, oversight, and review of PBMView entire presentation