Or. Admin. Code § 836-200-0440 - [Effective 6/29/2025] Market Conduct Requirements for Pharmacy Benefit Managers
(1) A pharmacy
benefit manager shall allow a network pharmacy to mail, ship or deliver
prescription drugs to its patients as an ancillary service. A contract between
a pharmacy benefit manager and a network pharmacy may establish limits and
parameters on the pharmacy's mail, shipment and/or delivery of prescription
drugs on the request of enrollees based on the pharmacy's total prescription
volume. A pharmacy benefit manager is not required to reimburse a delivery fee
charged by a network pharmacy unless the fee is specified in the contract
between the pharmacy benefit manager and the pharmacy.
(2) Except as provided in subsection (6) of
this section, a pharmacy benefit manager may require a prescription for a
specialty drug to be filled or refilled at a specialty pharmacy as a condition
for the reimbursement of the cost of a drug.
(3) For the purposes of subsection (2) of
this section, the department will consider a prescription drug to meet the
definition of "specialty drug" under Oregon Laws 2019, chapter 526, section 4
if, to be properly dispensed according to standard industry practice, the drug:
(a) Requires specialized preparation,
administration, handling, storage, inventory, reporting or
distribution;
(b) Is associated
with difficult or unusual data collection or administrative requirements;
or
(c) Requires a pharmacist to
manage the patient's use of the drug by monitoring, provide disease or
therapeutic support systems, provide care coordination including collaboration
with patients or other health care providers to manage adherence, identify side
effects, monitor clinical parameters, assess responses to therapy, or document
outcomes.
(4) For the
purposes of subsection (2) of this section, a pharmacy may demonstrate to the
department that it meets the definition of "specialty pharmacy" under Oregon
Laws 2019, chapter 526, section 4 by showing that:
(a) Its business is primarily providing
specialty drugs and specialized, disease-specific clinical care and services
for people with serious or chronic health conditions requiring complex
medication therapies; or
(b) It has
been validated for meeting quality, safety and accountability standards for
specialty pharmacy practice through accreditation in specialty pharmacy by a
nationally recognized, independent accreditation organization such as URAC or
the Accreditation Commission for Health Care (ACHC).
(5) Nothing in subsection (4) of this section
shall be construed to prohibit a pharmacy benefit manager from specifying
additional terms and conditions for a specialty pharmacy network contract,
including terms and conditions related to reimbursement.
(6) A pharmacy benefit manager shall
reimburse the cost of a specialty drug that is filled or refilled at a network
pharmacy that is a long term care pharmacy, provided that the specialty drug is
dispensed to an enrollee who is a resident of a long term care facility served
by the long term care pharmacy.
(7)
A network pharmacy may appeal its reimbursement from a pharmacy benefit manger
for a drug subject to maximum allowable cost pricing on the basis that the drug
is only available at the specified price if purchased in substantial quantities
in excess of its business needs. For the purposes of this subsection, a
quantity in excess of the business needs of a network pharmacy is defined as a
purchase quantity greater than a 3-month supply based on the pharmacy's total
dispensing history over the most recent rolling 12 months. A pharmacy benefit
manager may require a network pharmacy appealing its reimbursement for a drug
in accordance with this subsection to submit applicable evidence of its
dispensing history to the pharmacy benefit manager as part of the appeal
process. A pharmacy benefit manager's compliance with this subsection is
sufficient to demonstrate compliance with Oregon Laws 2019, chapter 526,
section 4 (1)(a)(B)(iii).
(8) If a
prescription drug subject to a specified maximum allowable cost is available at
that price if purchased in quantities that are consistent with the business
needs of some pharmacies but inconsistent with the business needs of others,
nothing in subsection (7) shall be construed to prohibit a pharmacy benefit
manager from applying the maximum allowable cost to pharmacies that can
purchase the drug in the necessary quantities consistent with their business
needs.
Notes
Statutory/Other Authority: Or Laws 2019, ch 526
Statutes/Other Implemented: Or Laws 2019, ch 526
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