Requirements for pharmacy benefit manager’s reimbursement for cost of drugs
- • rules
(1) As used in this section, “out-of-pocket cost” means the amount paid by an enrollee under the enrollee’s coverage, including deductibles, copayments, coinsurance or other expenses as prescribed by the Department of Consumer and Business Services by rule.
(2) A pharmacy benefit manager registered under ORS 735.532 (Registration of pharmacy benefit managers):
(a) May not require a prescription to be filled or refilled by a mail order pharmacy as a condition for reimbursing the cost of the drug.
(b) Except as provided in paragraph (c) of this subsection, 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 a drug.
(c) Shall reimburse the cost of a specialty drug that is filled or refilled at a network pharmacy that is a long term care pharmacy.
(d)(A) Shall allow a network pharmacy to mail, ship or deliver prescription drugs to its patients as an ancillary service.
(B) Is not required to reimburse a delivery fee charged by a pharmacy for a delivery described in subparagraph (A) of this paragraph unless the fee is specified in the contract between the pharmacy benefit manager and the pharmacy.
(e) May not require a patient signature as proof of delivery of a mailed or shipped prescription drug if the network pharmacy:
(A)(i) Maintains a mailing or shipping log signed by a representative of the pharmacy; or
(ii) Maintains each notification of delivery provided by the United States Postal Service or a package delivery service; and
(B) Is responsible for the cost of mailing, shipping or delivering a replacement for a drug that was mailed or shipped but not received by the enrollee.
(f) May not penalize a network pharmacy for or otherwise directly or indirectly prevent a network pharmacy from informing an enrollee of the difference between the out-of-pocket cost to the enrollee to purchase a prescription drug using the enrollee’s pharmacy benefit and the pharmacy’s usual and customary charge for the prescription drug.
(3) The Department of Consumer and Business Services may adopt rules to carry out the provisions of this section. [2019 c.526 §2]
Note: 735.536 (Requirements for pharmacy benefit manager’s reimbursement for cost of drugs) applies to pharmacy benefits and to contracts entered into, renewed or extended on or after January 1, 2021. See section 5, chapter 526, Oregon Laws 2019.
Note: See second note under 735.530 (Definitions for ORS 735.530 to 735.552).
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent. Currency Information