Or. Admin. Code § 410-121-0030

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-121-0030 - [Effective 3/29/2025] Practitioner-Managed Prescription Drug Plan

(1) The Practitioner-Managed Prescription Drug Plan (PMPDP) is a plan that ensures that OHP fee-for-service clients have access to the most effective prescription drugs appropriate for their clinical conditions at the best possible price:

(a) Licensed health care practitioners, who are informed by the latest peer reviewed research, make decisions concerning the clinical effectiveness of the prescription drugs;

(b) Licensed health care practitioners also consider the client's health condition, personal characteristics, and the client's gender, race, or ethnicity.

(c) The PDL includes over-the-counter (OTC) products determined to be cost-effective and clinically appropriate by the Oregon Pharmacy and Therapeutics (P & T) Committee. Select OTC product classes are included as a covered pharmacy benefit for Oregon FFS members.

(2) PMPDP Preferred Drug List (PDL):

(a) The PDL is the primary tool the Division uses to inform licensed health care practitioners about the results of the latest peer-reviewed research and cost effectiveness of prescription drugs;

(b) The PDL contains a list of prescription drugs that the Division, in consultation with the Drug Use Review (DUR)/Pharmacy & Therapeutics Committee (P & T), has determined represent the most effective drugs available at the best possible price;

(c) The PDL shall include drugs that are Medicaid reimbursable and the Food and Drug Administration (FDA) has determined to be safe and effective.

(3) PMPDP PDL Selection Process:

(a) The Division shall utilize the recommendations made by the P & T that result from an evidence-based evaluation process as the basis for selecting the most effective drugs;

(b) The Division shall ensure the drugs selected in section (3)(a) of this rule are the most effective drugs available for the best possible price and shall consider any input from the P & T about other FDA-approved drugs in the same class that are available for a lesser relative price. The Division shall determine relative price using the methodology described in section (4) of this rule;

(c) The Division shall evaluate selected drugs for the drug classes periodically:

(A) The Division may evaluate more frequently if new safety information, or the release of new drugs in a class, or other information makes an evaluation advisable;

(B) New drugs in classes already evaluated for the PDL shall be non-preferred until the new drug has been reviewed by the P & T;

(C) The Division shall make all revisions to the PDL using the rulemaking process and shall publish the changes on the Division's Pharmaceutical Services provider rules website.

(4) Relative cost and best possible price determination:

(a) The Division shall determine the relative cost of all drugs in each selected class that are Medicaid reimbursable and that the FDA has determined to be safe and effective;

(b) The Division may also consider dosing issues, patterns of use, and compliance issues. The Division shall weigh these factors with any advice provided by the P & T in reaching a final decision.

(5) Pharmacy providers shall dispense prescriptions in the generic form unless:

(a) The practitioner requests otherwise pursuant to OAR 410-121-0155;

(b) The Division notifies the pharmacy that the cost of the brand name particular drug, after receiving discounted prices and rebates, is equal to or less than the cost of the generic version of the drug.

(6) The exception process for obtaining non-preferred physical health drugs that are not on the PDL drugs shall be as follows:

(a) If the prescribing practitioner in their professional judgment wishes to prescribe a physical health drug not on the PDL, they may request an exception subject to the requirements of OAR 410-121-0040;

(b) The prescribing practitioner must request an exception for physical health drugs not listed in the PDL subject to the requirements of OAR 410-121-0060;

(c) Exceptions shall be granted when:

(A) The prescriber in their professional judgment determines the non-preferred drug is medically appropriate after consulting with the Division or the Oregon Pharmacy Call Center; or

(B) Where the prescriber requests an exception subject to the requirement of section (6)(b) of this rule and fails to receive a report of PA status within 24 hours, subject to OAR 410-121-0060.

(7) Table 121-0030-1, PMPDP PDL dated July 1, 2024 is adopted and incorporated by reference and is found at: www.orpdl.org.

(8) Table 121-0030-2, PMPDP OTC dated July 1, 2024 is adopted and incorporated by reference and is found at: www.orpdl.org.

Or. Admin. Code § 410-121-0030

OMAP 25-2002, f. 6-14-02 cert. ef. 7-1-02 OMAP 31-2002, f. & cert. ef. 8-1-02; OMAP 36-2002, f. 8-30-02, cert. ef. 9-1-02; OMAP 29-2003, f. 3-31-03 cert. ef. 4-1-03; OMAP 35-2003, f. & cert. ef. 5-1-03; OMAP 47-2003, f. & cert. ef. 7-1-03; OMAP 57-2003, f. 9-5-03, cert. ef. 10-1-03; OMAP 70-2003(Temp), f. 9-15-03, cert. ef. 10-1-03 thru 3-15-04; OMAP 82-2003, f. 10-31-03, cert. ef. 11-1-03; OMAP 9-2004, f. 2-27-04, cert. ef. 3-1-04; OMAP 29-2004, f. 4-23-04 cert. ef. 5-1-04; OMAP 34-2004, f. 5-26-04 cert. ef. 6-1-04; OMAP 45-2004, f. 7-22-04 cert. ef. 8-1-04; OMAP 81-2004, f. 10-29-04 cert. ef. 11-1-04; OMAP 89-2004, f. 11-24-04 cert. ef. 12-1-04; OMAP 19-2005, f. 3-21-05, cert. ef. 4-1-05; OMAP 32-2005, f. 6-21-05, cert. ef. 7-1-05; OMAP 58-2005, f. 10-27-05, cert. ef. 11-1-05; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; OMAP 32-2006, f. 8-31-06, cert. ef. 9-1-06; OMAP 48-2006, f. 12-28-06, cert. ef. 1-1-07; DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 16-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 36-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 39-2009, f. 12-15-09, cert. ef. 1-1-10; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 40-2010, f. 12-28-10, cert. ef. 1-1-11; DMAP 2-2011(Temp), f. & cert. ef. 3-1-11 thru 8-20-11; DMAP 19-2011, f. 7-15-11, cert. ef. 7-17-11; DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 12-2012(Temp), f. & cert. ef. 3-16-12 thru 9-11-12; DMAP 18-2012, f. 3-30-12, cert. ef. 4-9-12; DMAP 26-2012, f. & cert. ef. 5-14-12; DMAP 29-2012, f. & cert. ef. 6-21-12; DMAP 33-2012(Temp), f. 7-18-12, cert. ef. 7-23-12 thru 1-18-13; DMAP 40-2012(Temp), f. & cert. ef. 8-20-12 thru 1-18-13; DMAP 44-2012(Temp), f. & cert. ef. 9-26-12 thru 1-18-13; DMAP 61-2012, f. 12-27-12, cert. ef. 1-1-13; DMAP 6-2013(Temp), f. & cert. ef. 2-21-13 thru 8-19-13; DMAP 23-2013(Temp), f. 4-30-13, cert. ef. 5-1-13 thru 8-19-13; DMAP 43-2013, f. & cert. ef. 8-16-13; DMAP 76-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-30-14; DMAP 1-2014(Temp), f. & cert. ef. 1-10-14 thru 7-9-14; DMAP 15-2014(Temp), f. & cert. ef. 3-21-14 thru 9-17-14; DMAP 28-2014(Temp), f. & cert. ef. 5-2-14 thru 6-30-14; DMAP 37-2014, f. & cert. ef. 6-30-14; DMAP 47-2014(Temp), f. & cert. ef. 7-15-14 thru 1-11-15; DMAP 52-2014(Temp), f. & cert. ef. 9-16-14 thru 1-11-15; DMAP 64-2014(Temp), f. 10-24-14, cert. ef. 10-29-14 thru 12-30-14; DMAP 77-2014, f. & cert. ef. 12-12-14; DMAP 78-2014(Temp), f. & cert. ef. 12-12-14 thru 6-9-15; DMAP 88-2014(Temp), f. 12-31-14, cert. ef. 1-1-15 thru 6-29-15; DMAP 10-2015(Temp), f. & cert. ef. 3-3-15 thru 8-29-15; DMAP 26-2015(Temp), f. 4-17-15, cert. ef. 4-18-15 thru 6-26-15; DMAP 35-2015, f. 6-25-15, cert. ef. 6-26-15; DMAP 37-2015(Temp), f. & cert. ef. 7-1-15 thru 12-27-15; DMAP 57-2015(Temp), f. 9-30-15, cert. ef. 10-1-15 thru 12-27-15; DMAP 64-2015(Temp), f. & cert. ef. 11-3-15 thru 12-27-15; DMAP 66-2015(Temp), f. & cert. ef. 11-6-15 thru 12-27-15; DMAP 79-2015, f. 12-22-15, cert. ef. 12-27-15; DMAP 84-2015(Temp), f. 12-23-15, cert. ef. 1-1-16 thru 6-28-16; DMAP 18-2016(Temp), f. 4-28-16, cert. ef. 5-1-16 thru 6-28-16; DMAP 27-2016, f. 6-24-16, cert. ef. 6-28-16; DMAP 43-2016(Temp), f. & cert. ef. 7-1-16 thru 12-27-16; DMAP 57-2016(Temp), f. 9-30-16, cert. ef. 10-1-16 thru 3-29-17; DMAP 69-2016, f. & cert. ef. 12-1-16; DMAP 80-2016(Temp), f. 12-30-16, cert. ef. 1-1-17 thru 6-29-17; DMAP 14-2017(Temp), f. 4-28-17, cert. ef. 5-1-17 thru 6-29-17; DMAP 23-2017, f. & cert. ef. 6-29-17; DMAP 27-2017(Temp), f. 6-30-17, cert. ef. 7-1-17 thru 12-27-17; DMAP 51-2017, amend filed 12/05/2017, effective 12/05/2017; DMAP 33-2017(Temp), f. 8-24-17, cert. ef. 9-1-17 thru 12-27-17; DMAP 60-2017, temporary amend filed 12/27/2017, effective 01/01/2018 through 06/29/2018; DMAP 29-2018, amend filed 05/02/2018, effective 05/02/2018; DMAP 77-2018, temporary amend filed 06/27/2018, effective 07/01/2018 through 12/27/2018; DMAP 93-2018, temporary amend filed 10/16/2018, effective 10/16/2018 through 12/27/2018; DMAP 106-2018, amend filed 12/19/2018, effective 12/19/2018; DMAP 107-2018, temporary amend filed 12/20/2018, effective 1/1/2019 through 06/29/2019; DMAP 6-2019, temporary amend filed 03/19/2019, effective 4/1/2019 through 06/29/2019; DMAP 10-2019, temporary amend filed 04/24/2019, effective 5/15/2019 through 06/29/2019; DMAP 21-2019, amend filed 06/21/2019, effective 06/28/2019; DMAP 24-2019, temporary amend filed 06/25/2019, effective 7/1/2019 through 12/27/2019; DMAP 43-2019, temporary amend filed 10/24/2019, effective 11/01/2019 through 12/27/2019; DMAP 53-2019, amend filed 12/12/2019, effective 12/27/2019; DMAP 67-2019, temporary amend filed 12/27/2019, effective 01/01/2020 through 06/28/2020; DMAP 6-2020, temporary amend filed 02/25/2020, effective 03/01/2020 through 06/28/2020; DMAP 9-2020, temporary amend filed 03/16/2020, effective 04/01/2020 through 06/28/2020; DMAP 28-2020, amend filed 06/24/2020, effective 06/28/2020; DMAP 32-2020, temporary amend filed 06/26/2020, effective 7/1/2020 through 12/27/2020; DMAP 41-2020, temporary amend filed 08/25/2020, effective 9/1/2020 through 12/27/2020; DMAP 53-2020, temporary amend filed 09/28/2020, effective 10/1/2020 through 12/27/2020; DMAP 65-2020, amend filed 12/21/2020, effective 12/27/2020; DMAP 69-2020, temporary amend filed 12/28/2020, effective 1/1/2021 through 6/29/2021; DMAP 14-2021, temporary amend filed 03/30/2021, effective 4/1/2021 through 6/29/2021; DMAP 26-2021, amend filed 06/24/2021, effective 06/29/2021; DMAP 29-2021, temporary amend filed 06/29/2021, effective 7/1/2021 through 12/27/2021; DMAP 43-2021, temporary amend filed 09/27/2021, effective 10/1/2021 through 12/27/2021; DMAP 53-2021, temporary amend filed 12/28/2021, effective 12/28/2021; DMAP 54-2021, temporary amend filed 12/29/2021, effective 1/1/2022 through 6/25/2022; DMAP 45-2022, temporary amend filed 04/01/2022, effective 4/1/2022 through 6/25/2022; DMAP 61-2022, amend filed 06/26/2022, effective 6/27/2022; DMAP 64-2022, temporary amend filed 06/29/2022, effective 7/1/2022 through 12/27/2022; DMAP 75-2022, temporary amend filed 09/29/2022, effective 10/1/2022 through 12/27/2022; DMAP 87-2022, amend filed 12/13/2022, effective 12/20/2022; DMAP 95-2022, temporary amend filed 12/27/2022, effective 1/1/2023 through 6/24/2023; DMAP 10-2023, amend filed 03/28/2023, effective 4/1/2023; DMAP 54-2023, amend filed 06/30/2023, effective 7/1/2023; DMAP 78-2023, amend filed 09/23/2023, effective 10/1/2023; DMAP 96-2023, amend filed 12/22/2023, effective 1/1/2024; DMAP 84-2024, amend filed 04/04/2024, effective 4/4/2024; DMAP 109-2024, amend filed 07/01/2024, effective 7/1/2024; DMAP 125-2024, temporary amend filed 09/30/2024, effective 10/1/2024 through 3/29/2025

Statutory/Other Authority: ORS 413.032, 413.042, 414.065, 414.325, 414.330 - 414.414, ORS 414.312 & ORS 414.316

Statutes/Other Implemented: 414.065, 414.325, 414.334, 414.361, 414.369, 414.371, 414.353 & 414.354