Or. Admin. Code § 410-141-3855 - [Effective 5/6/2025] Pharmaceutical Services
(1) Prescription
drugs are a covered service for conditions that are described in the funded
region of the Prioritized List of Health Services, as described in OAR
410-141-3820. MCEs shall pay for
covered prescription drugs except:
(a) As
otherwise provided, mental health drugs that are in Standard Therapeutic Class
7 (ataractics-tranquilizers) or Standard Therapeutic Class 11
(psychostimulants-antidepressants) (based on the National Drug Code (NDC) as
submitted by the manufacturer to First Data Bank);
(b) Depakote, Lamictal, and their generic
equivalents and those drugs that the Authority specifically carved out from
capitation according to section (10) of this rule;
(c) Drugs covered under Medicare Part D when
the member is fully dual eligible; and
(d) Prescriptions for Physician Assisted
Suicide under the Oregon Death with Dignity Act, for which payment is governed
by OAR 410-121-0150.
(2) MCEs may use the statewide
Practitioner-Managed Prescription Drug Plan under ORS
414.330 to
414.337.
(3) MCEs may use a preferred drug list if it
allows access to other drug products not on the drug list through prior
authorization.
(4) As specified in
45 CFR
156.122 and
42 CFR
438.10, MCEs shall publish up-to-date,
accurate, and complete preferred drug lists, including any tiering structures,
that have been adopted and any coverage criteria or other restrictions on the
way certain drugs may be obtained. MCEs shall ensure that:
(a) The preferred drug list is easily
accessible to members and potential members, state and federal government, and
the public;
(b) The preferred drug
list is accessible on the MCE's public website in a machine-readable format
through a clearly identifiable web link or tab without requiring a member to
access account or policy number;
(c) Be made available in paper form if
requested by a member ; and
(d) If
an MCE has more than one plan, members may be easily able to discern which
preferred drug list applies to which plan.
(5) The preferred drug list shall:
(a) Include Federal Drug Administration (FDA)
approved drug products for each therapeutic class sufficient to ensure the
availability of covered drugs with minimal prior approval intervention by the
provider of pharmaceutical services;
(b) Include at least one item in each
therapeutic class of over-the-counter medications; and
(c) Be revised periodically to assure
compliance with this requirement.
(6) MCEs shall cover at least one form of
contraception within each of the 18 methods identified by the FDA. As set forth
in OAR 410-141-3515, the member may
refer themselves directly to family planning services without getting a
referral from a PCP or other participating providers.
(7) Prior Authorization for prescription drug
requests shall be addressed by the MCEs as described in OAR
410-141-3835.
(8) MCEs shall authorize the provision of a
drug requested by the Primary Care Provider or referring provider if the
prescriber certifies medical necessity for the drug such as:
(a) The equivalent of the drug listed has
been ineffective in treatment; or
(b) The drug listed causes or is reasonably
expected to cause adverse or harmful reactions to the member .
(9) MCEs may not authorize payment
for any Drug Efficacy Study Implementation (DESI) Less Than Effective (LTE)
drugs that have reached the FDA Notice of Opportunity for Hearing (NOOH) stage,
as specified in OAR 410-121-0420 (DESI)(LTE) Drug
List. DESI LTE drugs are identified by the Covered Outpatient Drug (COD) Status
equal to 05 or 06 in the federal "Drug Products in the Medicaid Drug Rebate
Program" list available at: https://data.medicaid.gov/
(10) The Authority shall pay for a drug that
is not included in the global budget pursuant to the Pharmaceutical Services
program rules (chapter 410, division 121), unless otherwise provided in this
rule. An MCE may not reimburse providers for carved-out drugs:
(a) An MCE may seek to add drugs to the
carve-out list contained in section (1) of this rule by submitting a request to
the Authority no later than March 1 of any contract year. The request must
contain all the following information:
(A) The
drug name;
(B) The FDA approved
indications that identify the drug may be used to treat a severe mental health
condition; and
(C) The reason the
Authority should consider this drug for carve out.
(b) If the Authority approves an MCE request
for a drug not to be paid within the global budget , the Authority shall exclude
the drug from the global budget for the following January contract cycle if the
Authority determines that the drug has an approved FDA indication for the
treatment of a severe mental health condition such as major depressive,
bi-polar, or schizophrenic disorders.
(11) MCEs shall submit quarterly encounter
data within 45 days after the end of the quarter pursuant to
42 CFR
438.3.
(12) MCEs are encouraged to provide payment
only for outpatient and physician-administered drugs produced by manufacturers
that have valid rebate agreements in place with the CMS as part of the Medicaid
Drug Rebate Program. MCEs may continue to have some flexibility in maintaining
preferred drug lists regardless of whether the manufacturers of those drugs
participate in the Medicaid Drug Rebate Program.
(13) MCEs shall utilize a Pharmacy and
Therapeutics (P & T) committee and a Drug Use Review (DUR) program. The
committees may work in tandem or independent of the other, if all committee
requirements for both committee types are met:
(a) A P & T committee must maintain
written documentation of the rationale for all decisions regarding the drug
list development and revisions. The committee shall follow the membership and
meeting standards specified in
45 CFR §
156.122(3)(i) and (ii).
Meetings shall be held at least quarterly;
(b) MCEs shall provide a detailed description
of its P & T committee including its DUR functions on an annual basis. The
report shall be in the form and manner required by the OHP. The data requested
by the Authority shall be calculated to meet federal reporting
obligations;
(c) The committee in
its DUR capacity shall assure prescriptions are appropriate, medically
appropriate, and not likely to result in adverse medical results. The committee
must be designed to educate prescribers and pharmacists to identify and reduce
the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or
medically unnecessary care. The committee shall include prospective DUR,
retrospective DUR, and educational programs as each is defined and described by
42 CFR 456, subpart K and Section 1902(oo) of the Social Security Act
[42 U.S.C.
1396a(oo)].
(14) As required by ORS 414.328,
CCOs shall implement a synchronization policy for the dispensing of
prescription drugs to members of the CCO. A "synchronization policy" means a
procedure for aligning the refill dates of a patient's prescription drugs so
that drugs that are refilled at the same frequency may be refilled
concurrently.
(15) Enrolled
providers are required to check the Prescription Drug Monitoring Program (PDMP)
as defined in ORS 431A.655 before prescribing a
schedule II controlled substance pursuant to
42
U.S.C 1396w-3a:
(a) Providers shall maintain documentation of
the prescription drug history of the individual being treated; and
(b) In the case that an enrolled provider is
not able to conduct the PDMP check, the providers shall maintain documentation
of efforts, including reasons why the provider was unable to conduct the
check;
(c) The PDMP check does not
apply to clients in exempt populations:
(A)
Individuals receiving hospice care;
(B) Individuals receiving palliative
care;
(C) Individuals receiving
cancer treatment;
(D) Individuals
with sickle cell disease;
(E)
Residents of long-term care facilities described in)
42
U.S.C. 1396d, or of another facility for
which frequently abused drugs are dispensed for residents through a contract
with a single pharmacy in accordance with
42
U.S.C. 1396w-3a(h)(2)(B);
and
(F) Individuals admitted to an
inpatient hospital facility. This exemption shall only apply to schedule II
controlled substances provided or administered to the individual admitted to
the inpatient hospital facility.
Notes
Statutory/Other Authority: ORS 413.042, 414.615, 414.625, 414.635 & 414.651
Statutes/Other Implemented: ORS 414.610-414.685
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