SB 5548 Population
(1)Certain individuals previously participating in the OSIP-MN Medically Needy Program as of January 31, 2003, and who are identified by the Authority with specific health-related conditions as outlined in the Joint Ways and Means budget note accompanying Senate Bill 5548 (2003) shall be referred to as SB 5548 clients.
(2)SB 5548 clients are eligible for a State-funded, limited, prescription drug benefit for covered drugs described in subsection (3) of this rule.
(3)Eligibility for and access to covered drugs for SB 5548 clients:
(a)SB 5548 clients must have been participating in the former OSIP-MN Medically Needy Program as of January 31, 2003, and as of that date had a medical diagnosis of HIV or organ transplant status;
(b)SB 5548 clients receiving anti-retroviral and other prescriptions necessary for the direct support of HIV symptoms:
(A)Must agree to participate in the Authority’s CareAssist Program in order to obtain access to this limited prescription drug benefit; and
(B)Prescriptions are limited to those listed on the CareAssist Formulary which can be found at http://www.ramsellcorp.com/individuals/or.aspx;
(c)SB 5548 clients receiving prescriptions necessary for the direct support of organ transplants are limited:
(A)Drug coverage includes any Medicaid reimbursable immunosuppressive, anti-infective or other prescriptions necessary for the direct support of organ transplants;
(B)Some drug classes are subject to restrictions or limitations based upon the Practitioner-Managed Prescription Drug Plan, OAR 410-121-0030 (Practitioner-Managed Prescription Drug Plan).
(4)Reimbursement for covered prescription drugs is limited by the terms and conditions described in this rule. This limited drug benefit provides State-funded reimbursement to pharmacies choosing to participate according to the terms and conditions of this rule:
(a)The Authority will send SB 5548 clients a letter from the Authority, instead of a Medical Care Identification, which will document their eligibility for this limited drug benefit;
(b)Retail pharmacies choosing to participate will be reimbursed for covered prescription drugs for the direct support of organ transplants described in subsection (3)(c) of this rule based upon Oregon Medicaid reimbursement levels as specified in the Division’s Pharmaceutical Services Program administrative rules 410-121-0155 (Reimbursement) and 410-121-0160 (Dispensing Fees).
(c)The Authority pharmacy benefits manager, will process retail pharmacy drug benefit reimbursement claims for SB 5548 clients;
(d)Mail order reimbursement will be subject to the Authority contract rates;
(e)Prescription drugs through the CareAssist program will be subject to the Authority contract rates;
(f)Reimbursement for this limited drug benefit is not subject to the following rules:
(A)410-120-1230, Client Copayments;
(B)410-121-0300 (CMS Federal Upper Limits for Drug Payments), Federal Upper Limit (FUL) for prescription drugs.
Rule 410-120-1195 — SB 5548 Population,