Okla. Admin. Code § 75:45-3-5

Current through Vol. 42, No. 4, November 1, 2024

Section 75:45-3-5 - Retail Pharmacy Network Access - Audi

(a)Authority. The Attorney General shall review and approve retail pharmacy network access for all pharmacy benefits managers (PBMs) to ensure compliance with 36 O.S. § 6961.

(b)Standards.

(1) 36 O.S. § 6960 defines a member of a "retail pharmacy network" as meaning retail pharmacy providers contracted with a PBM on behalf of a payor in which the pharmacy primarily fills and sells prescription medicine via retail storefront location.

(2) Pursuant to 36 O.S. § 6961(B), mail-order pharmacies shall not be used to meet access standards for retail pharmacy networks.

(3) Pursuant to 36 O.S. § 6961(C), PBMs shall not require patients to use pharmacies that are directly or indirectly owned by a PBM, including all regular prescriptions, refills, or specialty drugs regardless of the day supply.

(4) Pursuant to 36 O.S. § 6961(D), PBMs shall not in any manner on any material, including but not limited to mail and ID cards, include the name of any pharmacy, hospital, or other providers unless it specifically lists all pharmacies, hospitals, and providers.

(c)Required Monitoring by PBM. A PBM's retail pharmacy network access shall be monitored for compliance with this act by those insurers that utilize the services of such PBM. Health insurers are required to maintain retail pharmacy network access in conformity with the requirements set forth in 36 O.S. § 6961.

(d)Required Annual Audit by PBM. Every PBM shall conduct a network adequacy audit on an annual basis. If the audit reveals the percentage of covered individuals is less than one hundred and five percent (105%) above any of the required percentages in 36 O.S. § 6961, the PBM shall conduct semi-annual network adequacy audits until such time that an audit indicates that the percentage of covered individuals is more than five percent 5% above the required percentage. A PBM shall submit all audit reports on network adequacy, including any semi-annual network adequacy audits, to the Attorney General.

(e)Timing to Submit Audit Findings and Reports. The audits must be completed within ninety (90) days of the effective date of 36 O.S. § 6958-6968 and annually each year thereafter. The results of any audits shall be reported to the Attorney General within thirty (30) days of the completion of the audit. All mailed documents must be directed to the attention of the "PBM Enforcement and Compliance Unit." The PBM Enforcement and Compliance Unit may issue further guidance to PBMs on the process for submitting required reports to the Attorney General's Office.

Okla. Admin. Code § 75:45-3-5

Adopted by Oklahoma Register, Volume 41, Issue 21, July 15, 2024, eff. 7/25/2024