Or. Admin. Code § 410-121-0147

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

Section 410-121-0147 - Exclusions and Limitations

(1) The following items are not covered for payment by the Division of Medical Assistance Programs (Division) Pharmaceutical Services Program:

(a) Except as provided in section (2) of this rule, drug products for diagnoses below the funded line on the Health Evidence Review Commission (HERC) Prioritized List of Health Services or an excluded service under Oregon Health Plan (OHP) coverage;

(b) Home pregnancy kits;

(c) Fluoride for individuals over 18 years of age;

(d) Expired drug products;

(e) Drug products from non-rebatable manufacturers, with the exception of selected oral nutritionals, vitamins, and vaccines;

(f) Active Pharmaceutical Ingredients (APIs) and Excipients as described by Centers for Medicare and Medicaid (CMS);

(g) Drug products that are not assigned a National Drug Code (NDC) number;

(h) Drug products that are not approved by the Food and Drug Administration (FDA);

(i) Drug products dispensed for Citizenship Waived Medical (CWM) client benefit type except when prescribed as an emergency medical service as defined by OAR 410-134-0003(3). The CWM benefit plan ended on June 30, 2023;

(j) Drug Efficacy Study Implementation (DESI) drugs (see OAR 410-121-0420);

(k) Medicare Part D covered drugs or classes of drugs for fully dual eligible clients (see OAR 410-121-0149, 410-120-1200 & 410-120-1210).

(L) Drug products prescribed to establish or reestablish fertility or pregnancy;

(m) Drug products when prescribed for the treatment of sexual or erectile dysfunction;

(n) Drug products when prescribed for weight loss; and

(o) Drug products when primarily prescribed for cosmetic purposes or hair growth.

(2) The Division shall cover drug products for diagnoses below the funded line on the HERC Prioritized List of Health Services when such coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in Chapter 410 Division 151.

(3) The Division shall cover drug products from non-rebateable manufacturers under any one or a combination of the following circumstances:

(a) Coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in Chapter 410 Division 151;

(b) The drug is a vaccine; or

(c) The drug is an oral nutritional or vitamin selected for coverage by the Division.

(4) Effective on or after April 1, 2008, Section 1903(i) of the Social Security Act requires that written (nonelectronic) prescriptions for covered outpatient drugs for Medicaid clients be executed on a tamper-resistant pad in order to be eligible for federal matching funds. To meet this requirement, the Division shall only reimburse for covered Medicaid outpatient drugs only when the written (nonelectronic) prescription is executed on a tamper-resistant pad, or the prescription is electronically submitted to the pharmacy.

(5) Drugs requiring a skilled medical professional for safe administration shall be billed by the medical professional's office; unless otherwise specified by the Division.

Or. Admin. Code § 410-121-0147

HR 22-1993(Temp),f. & cert. ef. 9-1-93; HR 34-1993(Temp), f. & cert. ef. 12-1-93; HR 11-1994, f. 2-25-94, cert. ef. 2-27-94; HR 25-1994, f. & cert. ef. 7-1-94; HR 2-1995, f. & cert. ef. 2-1-95; HR 22-1997, f. & cert. ef. 10-1-97; OMAP 1-1999, f. & cert. ef. 2-1-99; OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 18-2004, f. 3-15-04 cert. ef. 4-1-04; OMAP 65-2005, f. 11-30-05, cert. ef. 1-1-06; OMAP 16-2006, f. 6-12-06, cert. ef. 7-1-06; DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 14-2011, f. 6-29-11, cert. ef. 7-1-11; DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 25-2022, minor correction filed 02/16/2022, effective 2/16/2022; DMAP 65-2022, amend filed 06/30/2022, effective 7/1/2022DMAP 55-2023, temporary amend filed 06/30/2023, effective 7/1/2023through 12/27/2023; DMAP 89-2023, amend filed 12/19/2023, effective 12/20/2023; DMAP 96-2023, amend filed 12/22/2023, effective 1/1/2024; DMAP 87-2024, amend filed 05/01/2024, effective 5/1/2024

Statutory/Other Authority: ORS 413.042 & ORS 414.065

Statutes/Other Implemented: ORS 414.065