Oregon Revised Statutes Chapter 735 § 735.536 — Requirements for pharmacy benefit manager’s reimbursement for cost of drugs;

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 licensed under ORS 735.532: (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 of 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 by imposing charges or fees, requiring contract amendments, canceling or terminating contracts or demanding recoupment or otherwise retaliate against a network pharmacy for: (A) 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; (B) Filing an appeal; (C) Filing a complaint against the pharmacy benefit manager with the Department of Consumer and Business Services; (D) Engaging in the legislative process; or (E) Challenging the pharmacy benefit manager’s practices or agreements. (g) May not charge a fee to a pharmacy for submitting claims or for the adjudication of claims. (3) The Department of Consumer and Business Services may adopt rules to carry out the provisions of this section. [2019 c.526 §2; 2024 c.87 §7] Note: See note under 735.530.