Pharmacy Benefit Managers' reporting requirements are mandated by the Oklahoma Patients Right to Pharmacy Choice Act, 36 O.S. §§ 6958 – 6968.
Effective November 1, 2023, authority to enforce the Oklahoma Patient’s Right to Pharmacy Choice Act, 36 O.S. §§ 6958, was transferred from the Oklahoma Insurance Department (“OID”) to the Oklahoma Office of the Attorney General (“OAG”). The Attorney General’s Pharmacy Benefit Management Compliance and Enforcement Unit (“OAG PBM Unit”) is committed to investigating and prosecuting violations of the Oklahoma Patients Right to Pharmacy Choice Act, 36 O.S. §§ 6958 – 6968 and the Pharmacy Audit Integrity Act, 59 O.S. §§ 356 – 356.5.
You may submit complaints to the OAG PBM Unit page.
The OID is responsible for handling all licensing applications and renewals, including the collection of any licensing fees.
The OAG is responsible for the enforcement of Oklahoma PBM laws that do not deal with the licensing application or renewal process.
Under the Patient’s Right to Pharmacy Choice Act, two types of reports must be submitted to the Attorney General’s Office.
Network Access Reports
PBMs operating in Oklahoma must report on the adequacy of its retail pharmacy network (“Network Access Reports”). A PBM can find details of the standards with which PBMs must comply under 36 O.S. § 6961. The report shall detail the PBM’s retail pharmacy networks and the access provided to covered individuals under 36 O.S. § 6961(A). Each PBM is required to submit its Network Access Report to the OAG no later than 45 days following the end of the second and fourth quarter of each calendar year. The Attorney General shall review and approve network access. See 36 O.S. § 6962.
Quarterly Data Reports
PBMs operating in Oklahoma must report to the OAG PBM Unit rebates and reimbursement data on a quarterly basis. The Quarterly Data Report includes both aggregates for each health insurer payor and individual amounts paid to the reimbursement of an individual pharmacy claim.
The template for the Quarterly Data Report can be downloaded from the Attorney General’s PBM Reporting webpage. The template contains three tabs. The first contains the report's identifying information: the PBM's name, contact information, and license number, as well as the reporting period covered in the subsequent tabs. OAG staff will use the contact information provided on the report to contact the PBM with follow-up questions. Please ensure that the contact information provided includes at least one person with knowledge of the information requested in the report.
Sheet 2 - REBATES ( Aggregate )
The second sheet, titled “REBATES (Aggregate),” seeks aggregate information for each health insurer payor doing business with the PBM. The purpose of the tab is to disclose any rebates received by the PBM as required by Oklahoma law. Please note this rebate data should include any fees, discounts, incentives, or rebates received from the manufacturer.
In addition to the payor name and identifying numbers, the template has spaces to report the total amount of rebates received, the amount of the rebates that are “passed through” to the health insurer payor, and the amount of the rebates that are passed to the insured or its members.
| Field Name | Explanation |
|---|---|
| Payor Name | The name of the health insurer payor |
| Group Number | The prescription group number denotes which group plan the member falls under. Typically, this number will represent the payor group, but an individual payor could have more than one group number if they have more than one plan. This has also been referred to as the “carrier account group” or “CAG.” |
| RxBIN | The BIN is the 6-digit Bank Identification Number used in electronic claims processing that identifies the insurance company or PBM. |
| PCN | The Processor Control Number further identifies the health plan for a claim. |
| Total Rebates | This represents the total dollar amount received in rebates in a given period for claims under a specific Insurer/ Payor or Health plan. Note: Rebates to Payor + Rebates to Insured + Rebates Retained by PBM = Total Rebates. |
| Rebates to Payor | This represents the total dollar amount of the rebates that were paid to the Insurer/Payor/Plan Sponsor, or “passed through to sponsor”. |
| Rebates to Insured | This represents the total dollar amount of the rebates that were paid to the covered party/enrollee of the health plan. |
Sheet 3 - CLAIMS (Individual)
The third sheet, titled “CLAIMS (Individual),” seeks individual claims data for each prescription fill. The purpose of the reporting is not to capture each attempted filing; rather to capture the final result of each prescription claim ie., if an identical claim is filed and paid but reversed, it is not necessary to include all attempted filings on the report. We require the final net result of each paid claim.
| Field Name | Explanation |
|---|---|
| Payor Name | The name of the health insurer payor |
| Group Number | The prescription group number denotes which group plan the member falls under. Typically, this number will represent the payor group, but an individual payor could have more than one group number if they have more than one plan. This has also been referred to as the “carrier account group” or “CAG.” |
| RxBIN | The BIN is the 6-digit Bank Identification Number used in electronic claims processing that identifies the insurance company or PBM. |
| PCN | The Processor Control Number further identifies the health plan for a claim. |
| Network Reimbursement ID | The Network Reimbursement ID (NRID) is provided by the PBM on pharmacy claims at point-of-sale. Based on the NRID, the pharmacy can identify the network that adjudicated each claim to help reconcile the pharmacy’s network agreements. The NRID is transmitted back to pharmacies in the reimbursement ID field (NCPDP field 545-2F) and represents the contractual exhibit from which the claim is adjudicating. |
| Pharmacy Name | Name of pharmacy where prescription is filled or dispensed. |
| Pharmacy NCPDP / NABP | The National Council for Prescription Drug Programs, (NCPDP) is an ANSI-accredited, standards development organization providing healthcare solutions. The NCPDP number (formerly known as the NABP number) is a unique identifier for any licensed pharmacy. |
| NPI | The National Provider Identification number is a unique id issued to healthcare providers including pharmacies, pharmacists, doctors, hospitals, etc. |
| Prescription Number | A unique identification number given to each prescription filled by a pharmacy. This number will refer to a specific prescription and its refills. |
| Claim Number | A unique number given to a pharmacy claim for reimbursement. This number will not be reused for a prescription’s subsequent refills. If Patient A has a maintenance medication filled monthly, there will be one Rx Number (Prescription Number) that refers to each occurrence of the dispensed medication. However, each time the prescription is filled, a claim for reimbursement is filed by the pharmacy to the PBM; each claim will be issued a unique Claim Number. |
| Product NDC | The National Drug Code is a unique 10-digit, 3-segment number. It is a universal product identifier for human drugs in the United States. The code is present on all nonprescription and prescription medication packages and inserts in the US. |
| Brand/Generic/Specialty | Indicate whether the drug is a brand drug (single-source or multi-source), generic, or specialty drug. If it is both, like a generic specialty, use “GS”, or for brands, use “BS”. |
| Quantity Dispensed | This field indicates the number of units, grams, milliliters, or other quantity dispensed in the current drug event. If the PDE was for a compounded item, the quantity dispensed is the total of all ingredients. |
| Days Supply | The intended duration of each prescription fill. |
| Number of Refills | Indicate the number of remaining refills associated with the prescription number at the time of its dispensing. |
| Dispensing Fee Paid | Amount paid to the pharmacy for dispensing the medication. |
| Amount Paid by Insurer | The total amount ($) paid by the insurer/payor to the PBM. |
| Amount paid to Provider/Pharmacy by PBM | The total amount ($) paid to the Provider/Pharmacy by the PBM. |
| Basis of Reimbursement Code | This is the method used to determine the amount of the reimbursement. The Basis of Reimbursement code is Field 522-FM in the NCPDP Payer Sheet Template. If any coding other than the NCPDP standard is used to denote the method of calculating the reimbursement, a key or explanation will be required. |
| Rebate from the Manufacturer | The total dollar figure that the PBM, including any affiliated GPO or rebate consultant, receives from the manufacturer for each specific prescription drug. |
| Rebate Paid to Payor/Insurer | The total dollar figure that the PBM, including any affiliated GPO or rebate consultant, passes or otherwise pays to the plan sponsor, insurer, patient, or payor for each specific prescription drug. |
| Fee Amount Charged by PBM or GPO | The total dollar figure that the PBM, including any affiliated GPO or rebate consultant, collects as payment, fees, or the like that is not passed to the plan sponsor, insurer, patient, or payor for each specific prescription drug. |
a. Network Access Reports
Network Access Reports are due to the OAG PBM Unit on a semi-annual basis. Network Access Reports are due 45 days following the closure of the covered period. August 15th is the deadline for the period of January 1 through June 30; and February 15th is the deadline for the period of July 1 through December 31. ‘
b. Section 6962 Quarterly Data Report
The Section 6962 Quarterly Data Report is due to the Attorney General’s Office one-year following the closure of each quarter. To ensure all rebates and post-adjudication adjustments have been made to the claims, the AG’s office has agreed to extend the due dates by a full year.
| Quarter | Due Date | Period Covered |
|---|---|---|
| Q2 2025 | 6/30/2025 | 4/1/2024 – 6/30/2024 |
| Q3 2025 | 9/30/2025 | 7/1/2024 – 9/30/2024 |
| Q4 2025 | 12/31/2025 | 10/1/2024 – 12/31/2024 |
| Q1 2026 | 3/31/2026 | 1/1/2025 – 3/31/2025 |
| Q2 2026 | 6/30/2026 | 4/1/2025 – 6/30/2025 |
The Attorney General’s Office is not required to grant any extension of the due date. Extensions will not be given without justification shown to the PBM Unit’s Director.
Any PBM who fails to comply with reporting requirements is subject to disciplinary action for violation of the Act and may be subject to license censure, suspension, revocation, and/or civil fines up to a maximum of $10,000. 36 O.S. § 6966.1(B)(1-2).
The templates for each report can be found on the Attorney General’s Office PBM webpage or by clicking below.
The AG’s Office takes the position that all claims adjudicated at Oklahoma pharmacies--regardless of whether the plan originated in Oklahoma or not--shall be reported in the quarterly reports.
We are happy to set up a secure share folder for you to upload your data. Our system includes FEDRAMP and HIPAA compliant encryption. Email us at PBMReporting@oag.ok.gov and let us know the email address of the individual who will be uploading the data. We will set up a private secure folder and send you a link which you can use to upload the data. We do not accept emails or file through any other file sharing portal.
Any additional questions can be sent to PBMReporting@oag.ok.gov and we will respond as soon as possible. Thank you.
