OAR 410-121-0147
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.

Source: Rule 410-121-0147 — Exclusions and Limitations, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0147.

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 410-121-0147’s source at or​.us