Exclusions and Limitations
(1)The following items are not covered for payment by the Division of Medical Assistance Programs (Division) Pharmaceutical Services Program:
(a)Drug products for diagnoses below the funded line on the Health Services Commission Prioritized List or an excluded service under Oregon Health Plan (OHP) coverage;
(b)Home pregnancy kits;
(c)Fluoride for individuals over 18 years of age;
(d)Expired drug products;
(e)Drug products from non-rebatable manufacturers, with the exception of selected oral nutritionals, vitamins, and vaccines;
(f)Active Pharmaceutical Ingredients (APIs) and Excipients as described by Centers for Medicare and Medicaid (CMS);
(g)Drug products that are not assigned a National Drug Code (NDC) number;
(h)Drug products that are not approved by the Food and Drug Administration (FDA);
(i)Drug products dispensed for Citizen/Alien-Waived Emergency Medical client benefit type;
(j)Drug Efficacy Study Implementation (DESI) drugs (see OAR 410-121-0420 (DESI Less-Than-Effective Drug List));
(k)Medicare Part D covered drugs or classes of drugs for fully dual eligible clients (see OAR 410-121-0149, 410-120-1200 (Excluded Services and Limitations) & 410-120-1210 (Medical Assistance Benefit Packages and Delivery System)).
(2)Effective on or after April 1, 2008, Section 1903(i) of the Social Security Act requires that written (nonelectronic) prescriptions for covered outpatient drugs for Medicaid clients be executed on a tamper-resistant pad in order to be eligible for federal matching funds. To meet this requirement, the Division shall only reimburse for covered Medicaid outpatient drugs only when the written (nonelectronic) prescription is executed on a tamper-resistant pad, or the prescription is electronically submitted to the pharmacy.
(3)Drugs requiring a skilled medical professional for safe administration will be billed by the medical professional’s office; unless otherwise specified by the Division.
Rule 410-121-0147 — Exclusions and Limitations,