Or. Admin. Code § 410-121-0030 - Practitioner-Managed Prescription Drug Plan
(1) The Practitioner-Managed Prescription
Drug Plan (PMPDP) is a plan that ensures that OHP fee-for-service clients have
access to the most effective prescription drugs appropriate for their clinical
conditions at the best possible price:
(a)
Licensed health care practitioners, who are informed by the latest peer
reviewed research, make decisions concerning the clinical effectiveness of the
prescription drugs;
(b) Licensed
health care practitioners also consider the client's health condition, personal
characteristics, and the client's gender, race, or ethnicity;
(c) The PDL includes over-the-counter (OTC)
products determined to be cost-effective and clinically appropriate by the
Oregon Pharmacy and Therapeutics (P & T) Committee. Select OTC product
classes are included as a covered pharmacy benefit for Oregon FFS
members.
(2) PMPDP
Preferred Drug List (PDL):
(a) The PDL is the
primary tool the Division uses to inform licensed health care practitioners
about the results of the latest peer-reviewed research and cost effectiveness
of prescription drugs;
(b) The PDL
contains a list of prescription drugs that the Division, in consultation with
the Drug Use Review (DUR)/Pharmacy & Therapeutics Committee (P & T),
has determined represent the most effective drugs available at the best
possible price;
(c) The PDL shall
include drugs that are Medicaid reimbursable and the Food and Drug
Administration (FDA) has determined to be safe and effective.
(3) PMPDP PDL Selection Process:
(a) The Division shall utilize the
recommendations made by the P & T that result from an evidence-based
evaluation process as the basis for selecting the most effective
drugs;
(b) The Division shall
ensure the drugs selected in section (3)(a) of this rule are the most effective
drugs available for the best possible price and shall consider any input from
the P & T about other FDA-approved drugs in the same class that are
available for a lesser relative price. The Division shall determine relative
price using the methodology described in section (4) of this rule;
(c) The Division shall evaluate selected
drugs for the drug classes periodically:
(A)
The Division may evaluate more frequently if new safety information, or the
release of new drugs in a class, or other information makes an evaluation
advisable;
(B) New drugs in classes
already evaluated for the PDL shall be non-preferred until the new drug has
been reviewed by the P & T;
(C)
The Division shall make all revisions to the PDL using the rulemaking process
and shall publish the changes on the Division's Pharmaceutical Services
provider rules website.
(4) Relative cost and best possible price
determination:
(a) The Division shall
determine the relative cost of all drugs in each selected class that are
Medicaid reimbursable and that the FDA has determined to be safe and
effective;
(b) The Division may
also consider dosing issues, patterns of use, and compliance issues. The
Division shall weigh these factors with any advice provided by the P & T in
reaching a final decision.
(5) Pharmacy providers shall dispense
prescriptions in the generic form unless:
(a)
The practitioner requests otherwise pursuant to OAR
410-121-0155;
(b) The Division notifies the pharmacy that
the cost of the brand name particular drug, after receiving discounted prices
and rebates, is equal to or less than the cost of the generic version of the
drug.
(6) The exception
process for obtaining non-preferred physical health drugs that are not on the
PDL drugs shall be as follows:
(a) If the
prescribing practitioner in their professional judgment wishes to prescribe a
physical health drug not on the PDL, they may request an exception subject to
the requirements of OAR
410-121-0040;
(b) The prescribing practitioner must request
an exception for physical health drugs not listed in the PDL subject to the
requirements of OAR 410-121-0060;
(c) Exceptions shall be granted when:
(A) The prescriber in their professional
judgment determines the non-preferred drug is medically appropriate after
consulting with the Division or the Oregon Pharmacy Call Center; or
(B) Where the prescriber requests an
exception subject to the requirement of section (6)(b) of this rule and fails
to receive a report of PA status within 24 hours, subject to OAR
410-121-0060.
(7) Table 121-0030-1, PMPDP PDL dated April
1, 2025, is adopted and incorporated by reference and is found at:
www.orpdl.org.
(8) Table
121-0030-2, PMPDP OTC dated January 1, 2025, is adopted and incorporated by
reference and is found at: www.orpdl.org.
Notes
Statutory/Other Authority: ORS 413.032, 413.042, 414.065, 414.312, 414.316, 414.325 & 414.330 - 414.414
Statutes/Other Implemented: ORS 414.065, 414.325, 414.334, 414.353, 414.354, 414.361, 414.369 & 414.371
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) The Practitioner-Managed Prescription Drug Plan (PMPDP) is a plan that ensures that OHP fee-for-service clients have access to the most effective prescription drugs appropriate for their clinical conditions at the best possible price:
(a) Licensed health care practitioners, who are informed by the latest peer reviewed research, make decisions concerning the clinical effectiveness of the prescription drugs;
(b) Licensed health care practitioners also consider the client's health condition, personal characteristics, and the client's gender, race, or ethnicity.
(c) The PDL includes over-the-counter (OTC) products determined to be cost-effective and clinically appropriate by the Oregon Pharmacy and Therapeutics (P & T) Committee. Select OTC product classes are included as a covered pharmacy benefit for Oregon FFS members.
(2) PMPDP Preferred Drug List (PDL) :
(a) The PDL is the primary tool the Division uses to inform licensed health care practitioners about the results of the latest peer-reviewed research and cost effectiveness of prescription drugs;
(b) The PDL contains a list of prescription drugs that the Division, in consultation with the Drug Use Review (DUR)/Pharmacy & Therapeutics Committee (P & T), has determined represent the most effective drugs available at the best possible price;
(c) The PDL shall include drugs that are Medicaid reimbursable and the Food and Drug Administration (FDA) has determined to be safe and effective.
(3) PMPDP PDL Selection Process:
(a) The Division shall utilize the recommendations made by the P & T that result from an evidence-based evaluation process as the basis for selecting the most effective drugs;
(b) The Division shall ensure the drugs selected in section (3)(a) of this rule are the most effective drugs available for the best possible price and shall consider any input from the P & T about other FDA-approved drugs in the same class that are available for a lesser relative price. The Division shall determine relative price using the methodology described in section (4) of this rule;
(c) The Division shall evaluate selected drugs for the drug classes periodically:
(A) The Division may evaluate more frequently if new safety information, or the release of new drugs in a class, or other information makes an evaluation advisable;
(B) New drugs in classes already evaluated for the PDL shall be non-preferred until the new drug has been reviewed by the P & T;
(C) The Division shall make all revisions to the PDL using the rulemaking process and shall publish the changes on the Division's Pharmaceutical Services provider rules website.
(4) Relative cost and best possible price determination:
(a) The Division shall determine the relative cost of all drugs in each selected class that are Medicaid reimbursable and that the FDA has determined to be safe and effective;
(b) The Division may also consider dosing issues, patterns of use, and compliance issues. The Division shall weigh these factors with any advice provided by the P & T in reaching a final decision.
(5) Pharmacy providers shall dispense prescriptions in the generic form unless:
(a) The practitioner requests otherwise pursuant to OAR 410-121-0155;
(b) The Division notifies the pharmacy that the cost of the brand name particular drug, after receiving discounted prices and rebates, is equal to or less than the cost of the generic version of the drug.
(6) The exception process for obtaining non-preferred physical health drugs that are not on the PDL drugs shall be as follows:
(a) If the prescribing practitioner in their professional judgment wishes to prescribe a physical health drug not on the PDL, they may request an exception subject to the requirements of OAR 410-121-0040;
(b) The prescribing practitioner must request an exception for physical health drugs not listed in the PDL subject to the requirements of OAR 410-121-0060;
(c) Exceptions shall be granted when:
(A) The prescriber in their professional judgment determines the non-preferred drug is medically appropriate after consulting with the Division or the Oregon Pharmacy Call Center; or
(B) Where the prescriber requests an exception subject to the requirement of section (6)(b) of this rule and fails to receive a report of PA status within 24 hours, subject to OAR 410-121-0060.
(7) Table 121-0030-1, PMPDP PDL dated October 1, 2024, is adopted and incorporated by reference and is found at: www.orpdl.org.
(8) Table 121-0030-2, PMPDP OTC dated October 1, 2024, is adopted and incorporated by reference and is found at: www.orpdl.org.
Notes
Statutory/Other
Statutes/Other Implemented: 414.065, 414.325, 414.334, 414.361, 414.369, 414.371, 414.353 & 414.354