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 2View entire presentation