OAR 436-009-0090
Pharmaceutical
(1)
General.(a)
Unless otherwise provided by an MCO contract, prescription medications do not require prior approval even after the patient is medically stationary.(b)
When a provider prescribes a brand-name drug, pharmacies must dispense the generic drug (if available), according to ORS 689.515 (Regulation of generic drugs). However, a patient may insist on receiving the brand-name drug and either pay the total cost of the brand-name drug out of pocket or pay the difference between the cost of the brand-name drug and generic to the pharmacy.(c)
Unless otherwise provided by MCO contract, the patient may select the pharmacy.(2)
Pharmaceutical Billing and Payment.(a)
Pharmaceutical billings must contain the National Drug Code (NDC) to identify the drug or biological billed. This includes compounded drugs, which must be billed by ingredient, listing each ingredient’s NDC. Ingredients without an NDC are not reimbursable.(b)
All bills from pharmacies must include the prescribing provider’s NPI or license number.(c)
Unless otherwise provided by contract, insurers must pay medical providers for prescription medication, including injectable drugs, at the medical provider’s usual fee, or the maximum allowable fee, whichever is less. However, drugs provided by a hospital (inpatient or outpatient) must be billed and paid according to OAR 436-009-0020 (Hospitals).(d)
Unless directly purchased by the worker (see 009-0025(5)), the maximum allowable fee for pharmaceuticals is calculated according to the following table: [Table not included. See ED. NOTE.](e)
Insurers must use a nationally published prescription pricing guide for calculating payments to the provider, e.g., RED BOOK or Medi-Span.(3)
Clinical Justification Form 4909.(a)
The prescribing provider must fill out Form 4909, Pharmaceutical Clinical Justification for Workers’ Compensation, and submit it to the insurer when prescribing more than a five day supply of the following drugs:(A)
Celebrex®,(B)
Cymbalta®,(C)
Fentora®,(D)
Kadian®,(E)
Lidoderm®,(F)
Lyrica®, or(G)
OxyContin®.(b)
Insurers may not challenge the adequacy of the clinical justification. However, they may challenge whether or not the medication is excessive, inappropriate, or ineffectual under ORS 656.327 (Review of medical treatment of worker).(c)
The prescribing provider is not required to fill out Form 4909 for refills of medications listed on that form.(d)
If a prescribing provider does not submit Form 4909, Pharmaceutical Clinical Justification for Workers’ Compensation, to the insurer, the insurer may file a complaint with the director.(4)
Dispensing by Medical Service Providers.(a)
Except in an emergency, prescription drugs for oral consumption dispensed by a physician’s or authorized nurse practitioner’s office are compensable only for the initial supply to treat the patient, up to a maximum of 10 days.(b)
For dispensed over-the-counter medications, the insurer must pay the retail-based fee.
Source:
Rule 436-009-0090 — Pharmaceutical, https://secure.sos.state.or.us/oard/view.action?ruleNumber=436-009-0090.