OAR 410-121-0157
Participation in the Medicaid Drug Rebate Program

(1)

The Oregon Medicaid Pharmaceutical Services Program is a participant in the Centers for Medicare and Medicaid Services (CMS) Medicaid Drug Rebate Program, created by the Omnibus Budget Reconciliation Act (OBRA) of 1990. The Patient Protection and Affordable Care Act (PPACA) enacted on March 23,2010 and the Health Care and Education Reconciliation Act of 2010, (HCERA) enacted on March 30, 2010, together called the Affordable Care Act, requires the Division to collect drug rebates for covered outpatient drugs dispensed to enrollees of Medicaid managed care organizations, (MCOs). The Medicaid Drug Rebate Program requires a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of the Department of Health and Human Services for States to receive federal funding for outpatient drugs dispensed to Medicaid patients. The drug rebate program is administered by CMS’s Center for Medicaid and State Operations (CMSO). Pharmaceutical companies participating in this program have signed agreements with CMS to provide rebates to the Division of Medical Assistance Programs (Division) on all their drug products. The Division will reimburse providers only for outpatient drug products manufactured or labeled by companies participating in this program.

(2)

Documents in rule by reference: Names and Labeler Code numbers for participants in the Medicaid Drug Rebate Program are the responsibility of and maintained by CMS. The Division receives this information from CMS in the form of numbered and dated Releases. The Division includes in rule by reference, the CMS Releases online at: https://www.medicaid.gov/medicaid/prescription-drugs/program-releases/index.html.

(3)

Retroactive effective dates: The CMS Medicaid Drug Rebate Program experiences frequent changes in participation and often this information is submitted to the Division after the effective date(s) of some changes. Therefore, certain participant additions and deletions may be effective retroactively. See specific instructions in the CMS Releases for appropriate effective date(s) of changes.

(4)

The Division contracts with a Pharmacy Benefit Manager (PBM) to manage the Medicaid Rebate Dispute Resolution program. Pharmacy providers must verify the accuracy of their Medicaid pharmacy claims with the PBM within 30 days of request in instances where drug manufacturers dispute their claim information. Verification can be photocopies of drug invoices showing that the billed products were in stock during the time of the date of service.

(5)

The actual National Drug Code (NDC) dispensed and the actual metric decimal quantity dispensed, must be billed.

Source: Rule 410-121-0157 — Participation in the Medicaid Drug Rebate Program, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0157.

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 410-121-0157’s source at or​.us