Okla. Admin. Code § 317:30-5-72
Current through Vol. 42, No. 4, November 1, 2024
Section 317:30-5-72 - [Effective 9/14/2025] Categories of service eligibility(a)Coverage for adults. Prescription drugs for categorically needy adults are covered as set forth in this subsection. (1) With the exception of (2) and (3) of this subsection, categorically needy adults are eligible for a maximum of six (6) covered prescriptions per month with a limit of two (2) brand name prescriptions. A prior authorization may be granted for a third brand name if determined to be medically necessary by OHCA and if the member has not already utilized their six (6) covered prescriptions for the month. (2) Subject to the limitations set forth in Oklahoma Administrative Code (OAC) 317:30-5-72.1, 317:30-5-77.2, and 317:30-5-77.3, exceptions to the six (6) medically necessary prescriptions per month limit are: (A) Unlimited monthly medically necessary prescriptions for categorically related individuals who are residents of nursing facilities(NF) or intermediate care facilities for individuals with an intellectual disability (ICF/IID); and (B) Seven (7) additional medically necessary prescriptions which are generic products per month to the six (6) covered under the State Plan [including three (3) brand name prescriptions] are allowed for adults receiving services under the 1915(c) Home and Community-Based Services (HCBS) waivers . Medically necessary prescriptions beyond the three (3) brand name or thirteen (13) total prescriptions will be covered with prior authorization. (3) For purposes of this Section, "exempt from the prescription limit" means claims filed for any of these prescriptions will not count toward the prescriptions allowed per month. Drugs exempt from the prescription limit include: (B) Anti-retroviral agents for persons diagnosed with Acquired Immune Deficiency Syndrome (AIDS) or who have tested positive for the Human Immunodeficiency Virus (HIV); (C) Frequently monitored prescription drugs. A complete list of the selected drugs considered as frequently monitored can be viewed on the agency's website at www.okhca.org. (D) Medication-assisted treatment (MAT) drugs for opioid use disorder; (G) Compensable smoking and tobacco cessation products; (H) Naloxone for use in opioid overdose; (I) Certain carrier or diluent solutions used in compounds (i.e. sodium chloride, sterile water, etc.); (J) Drugs used for the treatment of tuberculosis; and (4) When a brand drug is preferred over its generic equivalent due to lower net cost, that drug shall not count toward the brand limit; however, it will count toward the monthly prescription limit. (b)Coverage for children. Prescription drugs for SoonerCare eligible individuals under twenty-one (21) years of age are not limited in number per month, but may be subject to prior authorization, quantity limits or other restrictions. (c)Individuals eligible for Part B of Medicare. Individuals eligible for Part B of Medicare are also eligible for the Medicare Part D prescription drug benefit. Coordination of benefits between Medicare Part B and Medicare Part D is the responsibility of the pharmacy provider. The SoonerCare pharmacy benefit does not include any products which are available through either Part B or Part D of Medicare. (d)Individuals eligible for a prescription drug benefit through a Prescription Drug Plan (PDP) or Medicare Advantage - Prescription Drug (MA-PD) plan as described in the Medicare Modernization Act (MMA) of 2003. Individuals who qualify for enrollment in a PDP or MA-PD are specifically excluded from coverage under the SoonerCare pharmacy benefit. This exclusion applies to these individuals in any situation which results in a loss of Federal Financial Participation for the SoonerCare program. This exclusion shall not apply to items covered at OAC 317:30-5-72.1(2) unless those items are required to be covered by the prescription drug provider in the MMA or subsequent federal action. Okla. Admin. Code § 317:30-5-72
Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 14 Ok Reg 761, eff 12-24-96 (emergency); Amended at 14 Ok Reg 1785, eff 5-27-97; Amended at 15 Ok Reg 1114, eff 1-6-98 (emergency); Amended at 15 Ok Reg 1535, eff 5-11-98; Amended at 16 Ok Reg 54, eff 9-11-98 (emergency); Amended at 16 Ok Reg 685, eff 12-28-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3446, eff 7-1-99 (emergency)1; Amended at 17 Ok Reg 2383, eff 6-26-00; Amended at 19 Ok Reg 2773, eff 4-24-02 (emergency); Amended at 20 Ok Reg 1193, eff 5-27-03; Amended at 20 Ok Reg 2762, eff 7-1-03 (emergency); Amended at 20 Ok Reg 2881, eff 7-1-03 (emergency); Amended at 21 Ok Reg 398, eff 1-1-04 (emergency); Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 21 Ok Reg 2465, eff 7-11-05; Amended at 27 Ok Reg 614, eff 1-14-10 (emergency); Amended at 27 Ok Reg 949, eff 5-13-10 (emergency); Amended at 27 Ok Reg 1427, eff 6-11-10; Amended at 27 Ok Reg 949, eff 5-13-10 (emergency); Amended at 28 Ok Reg 1448, eff 6-25-11Amended by Oklahoma Register, Volume 31, Issue 24, September 2, 2014, eff. 9/12/2014Amended by Oklahoma Register, Volume 35, Issue 24, September 4, 2018, eff. 9/14/2018Amended by Oklahoma Register, Volume 37, Issue 24, September 1, 2020, eff. 9/14/2020Amended by Oklahoma Register, Volume 41, Issue 14, April 1, 2024, eff. 3/1/2024, exp. 9/14/2025 (Emergency)1On October 15, 1999, the District Court of Oklahoma County issued a Temporary Injunction Order "prohibiting, barring, enjoining and restraining the Oklahoma Health Care Authority from relying upon, maintaining, employing or using t[his] emergency rule." [See Astrazeneca LP v. Oklahoma Health Care Authority, Case No. CJ-99-5898, 10-15-99, Judge Bryan C. Dixon, District Court of Oklahoma County] On 6-26-00, the emergency action was superseded by a permanent action, and on 10-10-00, the case was dismissed with prejudice.