ORS 735.534
Claim reimbursement

  • maximum allowable costs
  • documentation
  • rules

(1)

As used in this section:

(a)

Intentionally left blank —Ed.

(A)

“Generally available for purchase” means a drug is available for purchase in this state by a pharmacy from a national or regional wholesaler at the time a claim for reimbursement is submitted by a network pharmacy.

(B)

A drug is not “generally available for purchase” if the drug:
(i)
May be dispensed only in a hospital or inpatient care facility;
(ii)
Is unavailable due to a shortage of the product or an ingredient;
(iii)
Is available to a pharmacy at a price that is at or below the maximum allowable cost only if purchased in substantial quantities that are inconsistent with the business needs of a pharmacy;
(iv)
Is sold at a discount due to a short expiration date on the drug; or
(v)
Is the subject of an active or pending recall.

(b)

“List” means the list of drugs for which maximum allowable costs have been established.

(c)

“Maximum allowable cost” means the maximum amount that a pharmacy benefit manager will reimburse a pharmacy for the cost of a drug.

(d)

“Multiple source drug” means a therapeutically equivalent drug that is available from at least two manufacturers.

(e)

“Therapeutically equivalent” has the meaning given that term in ORS 689.515 (Regulation of generic drugs).

(2)

A pharmacy benefit manager registered under ORS 735.532 (Registration of pharmacy benefit managers):

(a)

May not place a drug on a list unless there are at least two multiple source drugs, or at least one generic drug generally available for purchase.

(b)

Shall ensure that all drugs on a list are generally available for purchase.

(c)

Shall ensure that no drug on a list is obsolete.

(d)

Shall make available to each network pharmacy at the beginning of the term of a contract, and upon renewal of a contract, the specific authoritative industry sources, other than proprietary sources, the pharmacy benefit manager uses to determine the maximum allowable cost set by the pharmacy benefit manager.

(e)

Shall make a list available to a network pharmacy upon request in a format that:

(A)

Is electronic;

(B)

Is computer accessible and searchable;

(C)

Identifies all drugs for which maximum allowable costs have been established; and

(D)

For each drug specifies:
(i)
The national drug code; and
(ii)
The maximum allowable cost.

(f)

Shall update each list maintained by the pharmacy benefit manager every seven business days and make the updated lists, including all changes in the price of drugs, available to network pharmacies in the format described in paragraph (e) of this subsection.

(g)

Shall ensure that dispensing fees are not included in the calculation of maximum allowable cost.

(h)

May not reimburse a 340B pharmacy differently than any other network pharmacy based on its status as a 340B pharmacy.

(i)

May not retroactively deny or reduce a claim for reimbursement of the cost of services after the claim has been adjudicated by the pharmacy benefit manager unless the:

(A)

Adjudicated claim was submitted fraudulently;

(B)

Pharmacy benefit manager’s payment on the adjudicated claim was incorrect because the pharmacy or pharmacist had already been paid for the services;

(C)

Services were improperly rendered by the pharmacy or pharmacist; or

(D)

Pharmacy or pharmacist agrees to the denial or reduction prior to the pharmacy benefit manager notifying the pharmacy or pharmacist that the claim has been denied or reduced.

(3)

Subsection (2)(i) of this section may not be construed to limit pharmacy claim audits under ORS 735.540 (Definitions for ORS 735.540 to 735.552) to 735.552 (Pharmacy claims audits).

(4)

A pharmacy benefit manager must establish a process by which a network pharmacy may appeal its reimbursement for a drug subject to maximum allowable cost pricing. A network pharmacy may appeal a maximum allowable cost if the reimbursement for the drug is less than the net amount that the network pharmacy paid to the supplier of the drug. The process must allow a network pharmacy a period of no less than 60 days after a claim is reimbursed in which to file the appeal. An appeal requested under this section must be completed within 30 calendar days of the pharmacy making the claim for which appeal has been requested.

(5)

A pharmacy benefit manager shall allow a network pharmacy to submit the documentation in support of its appeal on paper or electronically and may not:

(a)

Refuse to accept an appeal submitted by a person authorized to act on behalf of the network pharmacy;

(b)

Refuse to adjudicate an appeal for the reason that the appeal is submitted along with other claims that are denied; or

(c)

Impose requirements or establish procedures that have the effect of unduly obstructing or delaying an appeal.

(6)

A pharmacy benefit manager must provide as part of the appeals process established under subsection (4) of this section:

(a)

A telephone number at which a network pharmacy may contact the pharmacy benefit manager and speak with an individual who is responsible for processing appeals;

(b)

A final response to an appeal of a maximum allowable cost within seven business days; and

(c)

If the appeal is denied, the reason for the denial and the national drug code of a drug that may be purchased by similarly situated pharmacies at a price that is equal to or less than the maximum allowable cost.

(7)

Intentionally left blank —Ed.

(a)

If an appeal is upheld under this section, the pharmacy benefit manager shall:

(A)

Make an adjustment for the pharmacy that requested the appeal from the date of initial adjudication forward; and

(B)

Allow the pharmacy to reverse the claim and resubmit an adjusted claim without any additional charges.

(b)

If the request for an adjustment has come from a critical access pharmacy, as defined by the Oregon Health Authority by rule for purposes related to the Oregon Prescription Drug Program, the adjustment approved under paragraph (a) of this subsection shall apply only to critical access pharmacies.

(8)

This section does not apply to the state medical assistance program.

(9)

The Department of Consumer and Business Services may adopt rules to carry out the provisions of this section. [2013 c.570 §11; 2013 c.570 §13; 2019 c.526 §4]
Note: See note under 735.530 (Definitions for ORS 735.530 to 735.552).

Source: Section 735.534 — Claim reimbursement; maximum allowable costs; documentation; rules, https://www.­oregonlegislature.­gov/bills_laws/ors/ors735.­html.

735.005
Definitions for ORS 735.005 to 735.145
735.015
Purpose
735.025
Construction
735.035
Application
735.045
Oregon FAIR Plan Association
735.055
Association board of directors
735.065
Required association functions
735.075
Discretionary association functions
735.085
Plan of operation
735.095
Contents of plan of operation
735.105
Regulation of association as insurer
735.115
Exemption of association from fees and taxes
735.145
Immunity from legal action in carrying out duties
735.150
Definitions for ORS 735.150 to 735.190
735.152
Application of laws
735.154
Rules
735.156
Confidentiality of documents and materials
735.158
Certificate of authority
735.160
Business name
735.162
Capital and surplus requirements
735.164
Incorporation of pure captive insurer and association captive insurer
735.166
Investment requirements for association captive insurer
735.168
Allowable risks for captive insurer
735.170
Rating organization
735.172
Reporting
735.174
Examination
735.176
Compliance with sound actuarial principles
735.178
Suspension or revocation of certificate of authority
735.180
Branch captive insurer as pure captive insurer
735.182
Examination of branch captive insurer and alien captive insurer
735.184
Requirements for foreign captive insurer to provide insurance in this state
735.186
Management of assets of captive reinsurer
735.188
Application of captive reinsurer for certificate of authority
735.190
Incorporation of captive reinsurer
735.200
Legislative findings
735.205
Definitions for ORS 735.200 to 735.260
735.210
Formation of market assistance plans
735.215
Findings prior to formation of joint underwriting association
735.220
Formation of joint underwriting association
735.225
Membership in joint underwriting association
735.230
Rates
735.235
Board of directors
735.240
Annual statement
735.245
Conditions for policyholder surcharge
735.250
Exemption from liability
735.255
State not liable to pay debts of association
735.260
Rules
735.265
Liquor liability insurance risk and rate classifications
735.300
Purpose of ORS 735.300 to 735.365
735.305
Definitions for ORS 735.300 to 735.365
735.310
Qualifications for risk retention group
735.315
Foreign risk retention groups
735.320
Relationship to insurance guaranty fund and joint underwriting association
735.325
Exemption of purchasing groups from certain laws
735.330
Purchasing groups
735.335
Purchase of insurance by purchasing group
735.340
Insurance Code enforcement authority subject to federal law
735.345
Violation of 735.300 to 735.365
735.350
Agent or broker
735.355
Court orders enforceable in Oregon
735.360
Rules
735.365
Short title
735.400
Purposes of ORS 735.400 to 735.495
735.405
Definitions for ORS 735.400 to 735.495
735.406
Cost of living adjustment to net worth, revenues and expenses of exempt commercial purchasers
735.410
Conditions for procuring insurance through nonadmitted insurer
735.415
Qualifications for placement of coverage with nonadmitted insurer
735.417
Insured required to report and pay taxes on independently procured insurance covering Oregon home state risks
735.418
Director authorized to enter into interstate compact for premium tax allocation
735.420
Declaration of ineligibility of surplus lines insurer
735.425
Filing by licensee after placement of surplus lines insurance
735.430
Surplus Line Association of Oregon
735.435
Evidence of insurance
735.440
Validity of contracts
735.445
Effect of payment of premium to surplus lines licensee
735.450
Requirements for license as surplus lines insurance licensee
735.455
Authority of licensee
735.460
Records of licensee
735.465
Monthly reports
735.470
Premium tax
735.475
Suit to recover unpaid tax
735.480
Suspension or revocation of license
735.485
Actions against surplus lines insurer
735.490
Jurisdiction in action against insurer
735.492
Application of certain Insurance Code provisions to surplus lines insurers
735.495
Short title
735.500
Requirements for certification as retainer medical practice
735.510
Notice to department of specified changes to practice
735.515
Charges for services not covered by contract
735.520
Oregon Essential Workforce Health Care Program
735.530
Definitions for ORS 735.530 to 735.552
735.532
Registration of pharmacy benefit managers
735.533
Denial, suspension or revocation of registration as pharmacy benefit manager
735.534
Claim reimbursement
735.536
Requirements for pharmacy benefit manager’s reimbursement for cost of drugs
735.540
Definitions for ORS 735.540 to 735.552
735.542
Pharmacy claims audits
735.544
Pharmacy claims audits
735.546
Pharmacy claims audits
735.548
Pharmacy claims audits
735.550
Pharmacy claims audits
735.552
Pharmacy claims audits
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