OAR 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.
(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) 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);
(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 (Reimbursement);
(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 (Prior Authorization Required for Drugs and Products);
(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 (How to Get Prior Authorization for Drugs);
(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) and fails to receive a report of PA status within 24 hours, subject to OAR 410-121-0060 (How to Get Prior Authorization for Drugs).
(7) Table 121-0030-1, PMPDP PDL dated April 1, 2021 is adopted and incorporated by reference and is found at: www.orpdl.org.

Source: Rule 410-121-0030 — Practitioner-Managed Prescription Drug Plan, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0030.

410‑121‑0000
Foreword and Definition of Terms 410‑121‑0021
Organizations Authorized to Provide Pharmaceutical Prescription Services 410‑121‑0030
Practitioner-Managed Prescription Drug Plan 410‑121‑0032
Supplemental Rebate Agreements 410‑121‑0033
Polypharmacy Profiling 410‑121‑0040
Prior Authorization Required for Drugs and Products 410‑121‑0060
How to Get Prior Authorization for Drugs 410‑121‑0061
Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs) 410‑121‑0100
Drug Use Review 410‑121‑0111
Pharmacy and Therapeutics Committee 410‑121‑0135
Pharmacy Management Program 410‑121‑0143
Client Confidentiality 410‑121‑0145
Prescription Requirements 410‑121‑0146
Dispensing Limitations 410‑121‑0147
Exclusions and Limitations 410‑121‑0148
Dispensing in a Nursing Facility or Community Based Care Living Facility 410‑121‑0150
Billing Requirements 410‑121‑0155
Reimbursement 410‑121‑0157
Participation in the Medicaid Drug Rebate Program 410‑121‑0160
Dispensing Fees 410‑121‑0185
Pharmacy Based Immunization Delivery 410‑121‑0190
Medication Therapy Management Services and Clozapine Therapy Monitoring 410‑121‑0200
Billing Forms 410‑121‑0220
Instructions for Completion of the Prescription Drug Invoice 410‑121‑0280
Billing Quantities, Metric Quantities and Package Sizes 410‑121‑0300
CMS Federal Upper Limits for Drug Payments 410‑121‑0420
DESI Less-Than-Effective Drug List 410‑121‑0580
Oregon Medicaid and Pharmaceutical Manufacturers’ Dispute Resolution Procedures 410‑121‑0625
Items Covered in the All-Inclusive Rate for Nursing Facilities
Last Updated

Jun. 8, 2021

Rule 410-121-0030’s source at or​.us