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Investor Presentaiton

implemented laws to ensure pharmacies are audited fairly and given a process for appeal. Oregon has some laws in place for pharmacy audit protections, though it is important to note current PBM regulatory statutes do not apply to Medicaid managed care PBM relationships or where insurers act as their own PBMs.5 Despite these laws, pharmacists have stated ongoing predatory practices are occurring and noted the existing appeals process is cumbersome and time-consuming. The Oregon Department of Consumer and Business Services can investigate complaints submitted by pharmacies against PBMs for some issues, including violation of MAC (maximum allowable cost) pricing requirements, predatory pharmacy audit practices, and violation of "gag clause" rules. Examples: Delaware and Ohio. Fair pharmacy reimbursement The number of pharmacies has been falling across the nation, and local, independent pharmacies have been impacted the most. Having access to a local pharmacy is critical in addressing health inequities and supporting positive health outcomes at the individual and population level. 6 Low reimbursement rates are often cited as a key factor for pharmacy closures and some states have provisions for fair reimbursement. Approaches from other states include prohibiting PBMs from reducing the amount reimbursed on a claim to effective rates or requiring the use of National Average Drug Acquisition Costs as a basis for reimbursements when available. Some states require PBMs to disclose the methodology for maximum allowable cost lists to provider pharmacies, and others have limited fees a PBM can levy on a pharmacy. Examples: Arkansas, Kentucky, and West Virginia. Enrollee protections Uniform formulary A formulary, or preferred drug list, is a list of prescription drugs that are covered under a health plan. Health plans use formularies as a way to negotiate drug rebates and encourage providers to prescribe those medications. Uniform formularies support administrative simplicity for providers and consistent drug coverage for patients. Some states with uniform formulary legislation for Medicaid require the same formulary for all managed care health plans, while others have chosen to adopt uniform formularies for only certain classes of drugs. See the FFS (Fee-For-Service) model below for more information on states that have entirely carved out pharmacy benefits from managed care, which would also produce a uniform formulary and coverage criteria for all Medicaid members. A shift to this structure should include considerations for phase-in implementation that would give prescribers and enrollees time to manage prescription changes, a mechanism for CCOS (coordinated care organizations) to access pharmacy claims, and drug utilization for care coordination. Examples: Mississippi, Ohio, and Washington. 5 Oregon Revised Statutes 735.530 -735.552 6 Oregon's Prescription Drug Program (OPDP) has a statutory charge to coordinate comprehensive prescription benefit services in Oregon and supports fair reimbursement practices through its 'Critical Access Pharmacy' designation. See Oregon Revised Statutes 414.312 and Oregon Administrative Rules 431-121 Oregon Secretary of State | September 2022 | page 2
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