Around the PIA Western Alliance States – Week of August 11, 2025

Oregon — ID 6-2025: Updates to Pharmacy Benefit Manager Rules and DPT Insurer Reporting Rule:

Rules: 836-053-1630, 836-200-0401, 836-200-0406, 836-200-0411, 836-200-0416, 836-200-0418, 836-200-0421, 836-200-0436, 836-200-0440

Summary: This rulemaking replaces references to registration throughout our current rules, encoded at OAR 836- 200-0401 et seq with references to licensure. It also adds new data elements to our reporting rule and new market conduct requirements. It also adds language clarifying the bar on retaliation against pharmacies, noting that a pharmacy claims audit may be considered retaliation under certain circumstances. Finally, the rulemaking includes substantial revisions to the language related to pharmacy reimbursement in order to clarify expectations for PBMs when a pharmacy is reimbursed below acquisition cost under a maximum allowable cost schedule.

Filed: July 29, 2025

Effective: August 1, 2025

Oregon — ID 5-2025: The Licensing of Public Adjusters:

Rules: 836-071-1100, 836-071-1105, 836-071-1110, 836-071-1115, 836-071-1120, 836-071-1125, 836-071-1130, 836-071-1135, 836-071-1140, 836-071-1145, 836-071-1150, 836-071-1155, 836-071-1160, 836-071-1165, 836-071- 1170, 836-071-1175, 836-071-1180, 836-071-1185, 836-071-1190, 836-071-1195

Summary: By adding/distinguishing a public adjuster license type from an independent adjuster type through rulemaking, the adjuster licensing process will be simplified for both the licensing section of the application, and the applying adjusters. Rulemaking is intended to clarify the roles and responsibilities of each adjuster type, further reduce potential for conflicts of interest, and add better regulatory oversight and consumer protection for distinctly different adjuster disciplines.

Filed: July 25, 2025

Effective: August 1, 2025

Washington — Kuderer fines Premera $550,000 for mental health parity, directory violations: Washington state Insurance Commissioner Patty Kuderer fined Premera Blue Cross $550,000 on Wednesday, Aug. 6, for violations of the Mental Health Parity and Addiction Equity Act and Washington’s provider directory regulation.

Along with the fine, Premera must update its provider directories by October 31 to comply with state regulations.

“These violations are a disservice to the people who rely on Premera’s health plans for their well-being,” Kuderer said. “Our laws are in place to ensure mental health services are just as accessible as medical services and we will keep holding the companies that don’t follow those laws accountable.”

The MHPAEA requires health carriers to explain the treatment limitations in their plans and how those limitations compare between behavioral health benefits and medical and surgical health benefits. The carriers must provide documentation explaining these limitations to the Office of the Insurance Commissioner upon request, which Premera was unable to do.

The Centers for Medicare and Medicaid Services provided the OIC with grants in 2018 and 2021 to determine whether Washington’s fully-insured health insurance markets offered comprehensive, affordable access to mental health and substance use services and treatment.

The OIC sent Premera market scans in 2019 and 2020 and opened a continuum in June 2022, which requested Premera provide its non-quantitative treatment limitation comparative analysis — details on benefit limits that aren’t expressed numerically, like prior authorization, step therapy, provider network restrictions, or medical necessities — and information on its provider directory.

Premera failed to provide sufficient documentation for its provider network access limitations. The company was also out of compliance with Washington’s provider directory regulation:

    Premera’s online provider directory on gender-affirming treatment was listed as “accurate as of December 7, 2021” rather than being updated monthly.

    Its printed provider directory didn’t include accessibility information for in-person facilities or explain how an enrollee could access those services.

    Its online provider directory didn’t specificy if a provider could be accessed without a referral.

    Its online provider directory allowed enrollees to search for providers offering telemedicine with no descriptions of, or instructions on how to access, those services.

Premera provided the OIC with an updated comparative analysis of benefit limitations in July 2025, including additional definitions, evidentiary sources, and data.

Learn more about mental health and substance use disorder coverage rights on the OIC’s behavioral health page.