OAR 410-121-0155
Reimbursement

(1) The Division shall pay the lesser of the provider’s billed amount or the ingredient cost plus a professional dispensing fee.
(2) The ingredient cost is established by the Division as follows:
(a) The Oregon Average Actual Acquisition Cost (OR-AAAC) of the drug;
(b) In cases where no OR-AAAC is available, the National Average Drug Acquisition Cost (NADAC);
(c) In cases where no OR-AAAC and no NADAC is available, the Wholesale Acquisition Cost (WAC).
(3) For ingredient cost for trade name forms of multiple source products:
(a) Except as provided in (3)(b) below, the Division shall apply the OR-AAAC or NADAC of the generic form when a trade name form of a multiple source product is dispensed;
(b) The Division shall pay the OR-AAAC or NADAC of the trade name form only when the prescribing practitioner certifies the trade version is required or when the brand drug is listed on the Division’s Preferred Drug List.
(4) The Division shall revise its OR-AAAC weekly. Pharmacies must make available to the Division or its contractor any information necessary to determine the pharmacy’s actual acquisition cost of drug products dispensed to the Division’s clients.
(5) The OR-AAAC shall serve as the basis for reimbursement. Individual pharmacies are required to participate in an OR-AAAC survey conducted by the Division or its contractor not more than one time per every 18 to 24-month period. Pharmacies that do not respond to OR-AAAC survey requests may be subject to disenrollment as providers for the Oregon Health Plan.
(6) If a provider is unable to purchase a particular drug product at the OR-AAAC, the provider shall report this to the Division or its contractor for further review through a dispute resolution process. Providers may submit inquiries via telephone, facsimile, via electronic mail, or the contractor’s secure web site: http://www.mslc.com/Oregon/AAACRateReview.aspx:
(a) The Division or its contractor shall respond to all inquiries or complaints within 24 hours and resolve the issue within five business days;
(b) The pricing dispute resolution process shall include the Division or its contractor verifying the accuracy of pricing to ensure consistency with marketplace pricing and drug availability;
(c) Price adjustments shall be made during the next weekly pricing update.
(7) The Division restricts claims for hemophilia blood factors to a single provider. This restriction does not apply for clients with other insurances or Medicare in addition to OHP. The sole source provider of blood factors is the Hemophilia Center at OHSU. Questions concerning hemophilia case management and blood factors shall be directed to this provider by calling: 877 346-0640.
(8) No professional dispensing fee is allowed for dispensing pill splitters/cutters or diabetic supplies and glucose monitors.
(9) Payment for pill splitters/cutters with a National Drug Code (NDC) number shall be reimbursed at the lesser of the billed amount or the ingredient cost and:
(a) A practitioner prescription is required; and
(b) The Division shall pay only for one pill splitter/cutter per client in a twelve-month period.
(10) A prescription is required for glucose monitors and related diabetic supplies.
(11) Payment for glucose monitors and related diabetic supplies billed with an NDC shall be reimbursed at a percentage of Medicare’s rate for the HCPCS procedure code. The Division’s reimbursement rates are listed in the Division’s fee schedule located at: http:/­/­www.oregon.gov/­OHA/­healthplan/­pages/­feeschedule.aspx.

Source: Rule 410-121-0155 — Reimbursement, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0155.

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 410-121-0155’s source at or​.us