OAR 836-200-0418: Aggregated Rebate and Payment Reports

(1) For the purposes of this rule, “health benefit plan” has the meaning defined in ORS 743B.005(16). (2) For the purposes of this rule, “pharmacy benefit manager” has the meaning defined in ORS 735.530. (3) For the purposes of this rule “administrative fee” has the meaning defined in ORS 735.537(a). (4) For the purposes of this rule, “dispensing fee” means an amount paid to a pharmacy licensed in Oregon for dispensing a prescription in addition to reimbursement for the cost of the drug. (5) No later than June 1 of each year, a pharmacy benefit manager required to be licensed with the Department of Consumer and Business Services must file a report using the form and manner prescribed by the department. The report must contain the following information for the immediately preceding calendar year: (a) The aggregated amount of rebates, fees, price protection payments, and any other payments the pharmacy benefit manager received from manufacturers related to managing the pharmacy benefits for carriers issuing health benefit plans in this state. This amount must include payments that the pharmacy benefit manager received from manufacturers directly and payments the pharmacy benefit manager received from manufacturers by the pharmacy benefit manager’s subsidiaries, any other entities that the pharmacy benefit manager holds an ownership in, or any entities which hold an ownership interest in the pharmacy benefit manager. This includes: (A) The aggregated amount of any payments, as described in subsection (5)(a) of this rule, that were passed on to carriers issuing health benefit plans in this state. (B) The aggregated amount of any payments, as described in subsection (5)(a) of this rule, that were passed on to enrollees in a health benefit plan at the point of sale in this state. (C) The aggregated amount of any payments, as described in subsection (5)(a) of this rule, that were retained as revenue by the pharmacy benefit manager. (b) The amount described in section (5)(a) of this rule should be equal to the sum of the amounts described in sections (5)(a)(A), (5)(a)(B), and (5)(a)(C) of this rule. (c) The total dispensing fees paid to the pharmacy benefit manager in this state from insurers, coordinated care organizations, and the Oregon Prescription Drug Program. (d) The total dispensing fees paid to pharmacies in this state by the pharmacy benefit manager. (e) The total administrative fees received from manufacturers and carriers. (f) The total administrative fees as described in subsection (e) that were retained by the pharmacy benefit manager. (g) The total amount of revenue received by the pharmacy benefit manager through spread pricing, pay-for-performance arrangements, or similar means which includes the following: (A) The difference between the total amount the pharmacy benefit manager reimbursed pharmacies in Oregon for prescriptions, inclusive of ingredient cost and dispensing fee, and the total amount the pharmacy benefit manager was reimbursed by carriers for prescriptions dispensed by pharmacies in Oregon; and (B) Any revenue obtained by the pharmacy benefit manager through spread pricing for prescriptions dispensed by pharmacies in Oregon as defined in ORS 735.537(1)(e).