Investor Presentaiton

Services Figure 7: Medicaid PBMs operate in a complex environment involving many different entities Drug rebates, performance incentives, market share payments, etc. Payment Money Drug manufacturer Rx drugs Placement on preferred drug list Rx drugs Drug wholesaler Rx drugs Payment 典 PBM Payment for services and drug rebate pass through Manages drug benefits CCO Capitation payments Reimbursements for pharmacy claims, admin fees, audit recoupments, etc. Community pharmacy Rx drugs ОНА Healthcare coverage Medicaid beneficiary enrolled in a CCO Source: Auditor-created, simplified model of Oregon's PBM structure based on information from OHA and the Congressional Budget Office. See also Appendix B for a comprehensive flowchart of Oregon's pharmaceutical supply chain. OHA pays CCOs predetermined rates, known as capitated payments, every month for each Medicaid client for covered services. CCOs receive these payments no matter how many or how few services a Medicaid client uses in a month. In 2023, the average capitated payment is $507.90, but rates vary among CCOs, age ranges, and other factors. CCOs pay providers and subcontractors, like PBMs, for services rendered and send encounter data to OHA. This data shows the services provided to clients and helps set future rates for capitated payments. Medicaid patients do not have out-of-pocket costs for prescription drugs, even if they have additional health insurance, which is always billed first. Figure 8 lists the 16 CCOs, their PBM subcontractors, and the number of people enrolled as of January 2023. Oregon Secretary of State | Report 2023-25 | August 2023 | page 8

View entire presentation