OAR 410-130-0180
Drugs
(1)
The Division of Medical Assistance Programs’ (Division) Medical-Surgical Services Program reimburses practitioners for drugs only when administered by the practitioner in the office, clinic or home settings. The Division does not reimburse practitioners for drugs that are self-administered by the client, except for contraceptives such as birth control pills, spermicides and patches:(a)
Use an appropriate Current Procedural Terminology (CPT) therapeutic injection code for administration of injectables;(b)
Use an appropriate Healthcare Common Procedure Coding System (HCPCS) code for the specific drug. Do not bill for drugs under code 99070; The Division requires both the NDC number and HCPCS codes on all claim forms.(c)
When there is no specific HCPCS code for a drug or biological, use an appropriate unlisted code from the list below and bill at acquisition cost (purchase price plus postage):(A)
J3490;(B)
J3590;(C)
J7599;(D)
J7699;(E)
J7799;(F)
J8499;(G)
J8999;(H)
J9999;(I)
Include the name of the drug, National Drug Code (NDC) number and dosage.(2)
Do not bill for local anesthetics; reimbursement is included in the payment for the tray and/or procedure.(3)
For codes requiring prior authorization and codes that are Not Covered/Bundled, refer to OAR 410-130-0200 (Prior Authorization) Table 130-0200-1 and OAR 410-130-0220 (Not Covered/Bundled Services/Not Valid) Table 130-0220-1.(4)
Not covered services and supplies include:(a)
Laetrile;(b)
Home pregnancy kits and products designed to promote fertility;(c)
Dimethyl sulfoxide (DMSO), except for instillation into the urinary bladder for symptomatic relief of interstitial cystitis;(d)
Infertility drugs;(e)
Sodium hyaluronate and Synvisc.(5)
Follow criteria outlined in the following:(a)
Billing Requirements — OAR 410-121-0150 (Billing Requirements);(b)
Brand Name Pharmaceuticals — OAR 410-121-0155 (Reimbursement);(c)
Prior Authorization Procedures — OAR 410-121-0060 (How to Get Prior Authorization for Drugs);(d)
Drugs and Products Requiring Prior Authorization — OAR 410-121-0040 (Prior Authorization Required for Drugs and Products);(e)
Drug Use Review — OAR 410-121-0100 (Drug Use Review);(f)
Participation in Medicaid’s Drug Rebate Program — OAR 410-121-0157 (Participation in the Medicaid Drug Rebate Program).(A)
The Division cannot reimburse providers for a drug unless the drug manufacturer has signed an agreement with the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicaid Drug Rebate Program.(B)
To verify that a drug manufacturer participates in the Medicaid Drug Rebate Program, visit the CMS website below to verify that the first five digits of the NDC number (labeler code) are listed as a participating drug company: https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/data/index.html.(6)
Clozaril/Clozapine therapy:(a)
Clozapine is covered only for the treatment of clients who have failed therapy with at least two anti-psychotic medications;(b)
Clozapine supervision is the management and record keeping of clozapine dispensing as required by the manufacturer of clozapine. This is part of an evaluation and management service conducted by the appropriately licensed prescribing medical practitioner;(c)
Pharmacies dispensing clozapine shall comply with OAR 410-121-0190 (Medication Therapy Management Services and Clozapine Therapy Monitoring).
Source:
Rule 410-130-0180 — Drugs, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-130-0180.