(1)The Division of Medical Assistance Programs (Division) will reimburse the pharmacy for dispensed medication the lesser of:
(a)The quantity indicated by the prescriber on the prescription;
(b)The quantity indicated by the Division dispensing limitations as outlined in this rule; or
(c)The quantity needed for Prescription Synchronization.
(2)The pharmacy may only dispense less than the prescribed quantity when the prescribed quantity exceeds the Division’s dispensing limitations, or when a lesser quantity is needed for Prescription Synchronization.
(3)The pharmacy may, at the client’s direction, dispense less than the prescribed quantity of a maintenance medication in order to align the refill dates if the client has received the same dose for two months or more. (4) Unless otherwise specified in this rule, the Division will not reimburse claims for medications exceeding a 34-day supply.
(5)Exceptions to the 34-day supply do not apply to claims for the following Standard Therapeutic Classes of medications. Claims exceeding a 34-day supply for these medications will not be reimbursed under any circumstances:
(a)Ataractics, Tranquilizers — 07;
(b)Muscle Relaxants — 08;
(c)CNS Stimulants — 10;
(d)Psychostimulants, Antidepressants — 11;
(e)Amphetamine Preps — 12;
(f)Narcotic Analgesics — 40;
(g)Sedative Barbiturate — 46;
(h)Sedative Non-Barbiturate — 47.
(6)The Division will allow reimbursement for more than a 34-day supply if the medication’s original package size cannot be divided.
(7)Except for medications listed in (5), claims for up to a 100-day supply of the following types of medications may be reimbursed to the Division’s mail order pharmacy contractor, Indian Health mail order pharmacy providers, and 340B providers:
(a)A preferred PDL generic; and
(b)A generic drug not on the PDL, costing $10 per month or less.
(8)Any pharmacy provider will be reimbursed for up to a 100-day supply of family planning drugs.
(9)Maintenance Medications — Any pharmacy provider will be reimbursed for up to a 100-day supply of select classes of medications if the client has received the same dose for two months or more. Maintenance medications shall be determined by the Division based on the following criteria:
(a)Have low probability for dosage or therapy changes due to side effects; and
(b)Are used most commonly to treat a chronic disease state and not considered curative or promoting recovery; and
(c)Are administered continuously rather than intermittently.
(10)Selected medications identified by the Division will be limited to a 15-day supply for initial fills. These medications have been identified as having high side effect profiles, high discontinuation rates, or needing frequent dose adjustments.
(11)After stabilization of a diabetic, the pharmacy should provide a minimum of a one-month supply of insulin per dispensing.
(12)For vaccines available in multiple dose packaging, the Division will allow a dispensing fee for each multiple dose. When vaccines are administered at the pharmacy, refer to Oregon Administrative Rule (OAR) 410-121-0185 (Pharmacy Based Immunization Delivery).
(a)For compounded prescriptions, bill components of the prescription separately. Third party payments for compounded prescriptions must be split and applied equally to each component;
(b)The Division will consider any other form of prescription splitting as a billing offense and take appropriate action as described in the General Rules (OAR 410 division 120).
Rule 410-121-0146 — Dispensing Limitations,