PBM Reporting
Effective November 1, 2023, the Oklahoma Office of the Attorney General has enforcement authority under the provisions of the Patient's Right to Pharmacy Choice Act, 36 O.S. §§ 6958-6971.
Fraud, Willful Misrepresentation, or Abuse (FWA) Audit Reporting
Pursuant to 59 O.S. § 356.3(E): "Any entity conducting an audit that is based on or involves fraud, willful misrepresentation, or abuse shall provide to the Office of the Attorney General:
- Notice at least two (2) calendar days prior to beginning performance of an audit;
- A preliminary report within thirty (30) calendar days of performing the audit pursuant to this section; and
- A final report within thirty (30) calendar days following the closure of the final appeal period for an audit performed pursuant to this section."
Provide Notice of FWA Audit
To submit the required advance notice of an audit based on suspicion of FWA:
- Step 1: Identify the claims to be included in the audit by downloading and completing the FWA Audit Claimstemplate:
Section 6962 Quarterly Reports
Effective November 1, 2023, the Oklahoma Office of the Attorney General has enforcement authority under the provisions of the Patient's Right to Pharmacy Choice Act, 36 O.S. §§ 6958-6971.
The Act requires each Pharmacy Benefit Manager (PBM) operating in the State to report on a quarterly basis, for each health insurer payor, the following information:
- the aggregate amount of rebates received by the PBM,
- the aggregate amount of rebates distributed to the appropriate health insurer payor,
- the aggregate amount of rebates passed on to the enrollees of each health insurer payor at the point of sale that reduced the applicable deductible, copayment, coinsure or other cost sharing amount of the enrollee,
- the individual and aggregate amount paid by the health insurer payor to the PBM for pharmacy services itemized by pharmacy, drug product and service provided, and
- the individual and aggregate amount a PBM paid a provider for pharmacy services itemized by pharmacy, drug product and service provided.
36 O.S. § 6962(D)(5)
Reporting should be submitted using the template provided below. Please make no changes to the format of the template and be careful to complete both tabs included. The report should be submitted in MS Excel (.xlsx) format and emailed to PBMReporting@oag.ok.gov no later than 45 days after the end of the reporting quarter.
Each report submission must be accompanied by an attestation of authenticity signed by the representative of the PBM who prepares the report. Download the fillable Attestation PDF template. This document attests to the accuracy and completeness of the information contained in the reports.
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).
| Quarter | Due Date | Period Covered |
|---|---|---|
| Q2 2024 | June 30, 2024 | 04/1/2023 – 06/30/2023 |
| Q3 2024 | September 30, 2024 | 07/01/2023 – 09/30/2023 |
| Q4 2024 | December 31, 2024 | 10/01/2023 – 12/31/2023 |
| Q1 2025 | March 30, 2025 | 01/01/2024 – 03/31/2024 |
Network Access Adequacy Standards
The Patient’s Right to Pharmacy Choice Act, Title 36 O.S.§§ 6958 – 6968, requires pharmacy benefits managers (“PBMs”) doing business in the State of Oklahoma to comply with certain pharmacy network adequacy standards. The Oklahoma Office of the Attorney General (“OAG”) is required by the Act to review and approve retail pharmacy network access for all Oklahoma-licensed PBMs. 36 O.S.§§ 6962. These reviews will be completed semi-annually.
Each PBM licensed in the State of Oklahoma is required to submit its “Oklahoma Pharmacy Benefits Manager Retail Pharmacy Network Access Report” to the OAG no later than 45 days following the end of the 2nd and 4th quarter of each calendar year (see schedule below). Such a report shall detail the PBM’s retail pharmacy networks and the access provided to covered individuals under Title 36 O.S. § 6961(A).
In addition, the OAG requires all Oklahoma licensed PBMs to provide notice before making any significant retail pharmacy network change that may impact Oklahoma consumer access to a retail pharmacy network within their corresponding access standard area(s) as required by the Act. 36 O.S. § 6961. This may include but is not limited to, any mergers or acquisitions.
Every Oklahoma Pharmacy Benefits Manager Retail Pharmacy Network Access Report is submitted using the attached template in MS Excel format that is searchable and in a manner that allows for the data to be arranged and organized. The report should include no redaction, encryption, or password protection. Please make no changes to the format of the template. The MS Excel file should be named with the following convention that identifies the PBM’s Oklahoma License number, the year, the semi-annual period included, and the report’s description (see example below).
The Oklahoma Pharmacy Benefits Manager Retail Pharmacy Network Access Report is organized into multiple sheets (or tabs) for submission of the required information. Please ensure that each of the following sheets is accurately completed.
- PBM Affiliations;
- Geo Access Report Summary; On this sheet the PBM will list all of its pharmacy networks by name and type (retail or preferred) and provide the other information as indicated;
- For each of its networks, the PBM will fill out the following three (3) sheets, renaming such sheets as appropriate, and adding additional sheets as needed in the same format:
- Network A – Retail Pharmacies (or Preferred Pharmacies)
- Network A – Retail Dot Map (or Preferred Rx Dot Map)
- Network A – Retail Rx Adequacy (or Preferred Rx Adequacy)
Each report submission must be accompanied by a general attestation of authenticity (see below) signed by the representative of the PBM who prepares the report.
Attestation Example: “In compliance with Title 36 O.S. §§ 6958 - 6968, the Oklahoma Pharmacy Benefits Manager Retail Pharmacy Network Access Report herein attached is submitted to be filed with the Oklahoma Office of the Attorney General on behalf of [PBM legal name]. I hereby attest to the accuracy of the data and facts represented within this document as of [Date submitted].”
Reports should be submitted electronically to PBMReporting@oag.ok.gov. Thank you in advance for your assistance and timely response. Failure to timely submit any reports is considered a violation and subject to disciplinary action under 36 O.S. § 6966.1(B).
| REPORTING PERIOD | REPORT DUE | FILE NAME |
|---|---|---|
| 07/01/2023 - 12/31/2023 | 02/15/2024 | 111111_2023S2_Network_Access_Report.xlsx |
| 01/01/2024 - 06/30/2024 | 08/15/2024 | 111111_2024S1_Network_Access_Report.xlsx |
| 07/01/2024 - 12/31/2024 | 02/15/2025 | 111111_2024S2_Network_Access_Report.xlsx |
If you are a representative of a Pharmacy Benefits Manager with any questions or concerns regarding your reporting requirements, please do not hesitate to email us at PBMReporting@oag.ok.gov. If you are a pharmacist or a patient and feel you have been a victim of a violation of the Patient's Right to Pharmacy Choice Act, submit a complaint on the PBM page.
