OAR 410-121-0135
Pharmacy Management Program

(1)

The Pharmacy Management Program promotes the appropriate use of quality pharmaceutical services by identifying and correcting overutilization of services.

(2)

The Pharmacy Management Program limits some fee-for-service clients to receiving their prescription drugs through the following sources:

(a)

A single retail pharmacy to pick up prescriptions;

(b)

The Division of Medical Assistance Program (Division) mail order pharmacy contractor; and

(c)

A specialty pharmacy.

(3)

The Division will not include the following clients in the Pharmacy Management Program:

(a)

Members enrolled in a Coordinated Care Organization;

(b)

Clients with Medicare drug coverage in addition to OHP;

(c)

Children in the care and custody of the Department of Human Services; or

(d)

Inpatients or residents in a hospital, nursing facility, other medical institution or long term care facility.

(4)

The Division will consider referrals of potential Pharmacy Management Program clients from the following sources:

(a)

Providers;

(b)

Division staff; and

(c)

Division contractors.

(5)

Reasons for referring a client to the Division for potential enrollment in the Pharmacy Management Program shall be limited to factors that indicate possible overutilization or drug misuse, or that raise concern for patient safety. Those factors are:

(a)

Use of three or more pharmacies during the prior six months;

(b)

Fills prescriptions from more than one prescriber for the same or comparable medications; or

(c)

Evidence that the client altered a prescription; or

(d)

Exhibits behaviors or patterns of behavior that the Pharmacy and Therapeutics Committee has identified as indicative of intentional overutilization or misuse.

(6)

Clients referred to the Division for potential enrollment in the Pharmacy Management Program shall be enrolled in the program only when a licensed pharmacist appointed by the Division conducts a review and concludes the individual utilized pharmaceutical items or services at a frequency or amount that is not medically necessary based on factors including, but not limited to, those described in subsection (5) of this rule.

(7)

When the Division concludes enrollment in the Pharmacy Management Program is appropriate as described in subsection (6), the Division shall send the client a notice that provides the following information:

(a)

The Division plans to require that the client use a designated pharmacy for a 12-month period;

(b)

The specific date when the requirement will begin;

(c)

An explanation of the reason for enrollment in the Pharmacy Management Program, and the benefits of enrollment in the Pharmacy Management Program; and

(d)

The client’s right to request the following, within 45 days of the date of the notice:

(A)

A different designated pharmacy; and

(B)

An administrative hearing to appeal the Division’s decision to enroll the client into the Pharmacy Management Program.

(8)

Changing the Pharmacy Management Program client’s enrolled pharmacy:

(a)

Clients may change their enrolled pharmacy if they:

(A)

Move out of area;

(B)

Are reapplying for OHP benefits; or

(C)

Are denied access to pharmacy services by their selected pharmacy for reasons other than the Pharmacy Management Program factors identified by the Division;

(b)

Clients cannot change their choice of pharmacy more than once every 3 months.

(9)

Pharmacy Management Program clients may receive drugs from a different pharmacy if the client urgently needs to fill a prescription and the enrolled pharmacy:

(a)

Is not available;

(b)

Does not have the prescribed drug in stock; or

(c)

Is more than 50 miles away from the client’s location at the time the prescription needs to be filled. However, DMAP may deny coverage if the client frequently fills prescriptions out of the area of the enrolled pharmacy.

(10)

Call the Oregon Pharmacy Help Desk for authorization to fill a prescription in the situations described in (9)(a)–(c) above.

(11)

The client’s appeal rights and the process for appealing a Division decision to enroll a client in the Pharmacy Management Program are found in OAR 410-120-1860 (Contested Case Hearing Procedures). If the client requests an administrative hearing before the effective date of the client notice and requests that the services be continued, the Authority shall continue the services pursuant to OAR 410-120-1865 (Denial, Reduction, or Termination of Services).

Source: Rule 410-121-0135 — Pharmacy Management Program, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0135.

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 410-121-0135’s source at or​.us