Or. Admin. R. 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. 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.
(d) Unless directly purchased by the worker
(see OAR 436-009-0025(5)),
the maximum allowable fee for pharmaceuticals is calculated according to the
following table: [See attached table.]
(e) Insurers must use a nationally published
prescription pricing guide for calculating payments to the provider, e.g., RED
BOOK or Medi-Span.
(3)
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.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 656.726(4)
Statutes/Other Implemented: ORS 656.248, ORS 656.252 & ORS 656.254
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