Oregon Administrative Code

410-120-2025 HRSN Person-Centered Service Plan (PCSP) (1) Upon authorization of HRSN Services, the MCE or, as applicable, the Authority, shall, together with the HRSN Authorized Member, update their Care Plan as outlined in OAR 410-141-3870 to include an HRSN PCSP for the authori…

410-120-2030 HRSN Service Provider Qualifications (1) MCEs and the Authority shall ensure that all contracted HRSN Service Providers meet both the general qualifications described in (2)(a-j) below and the domain and service-specific qualifications described in (3) – (6) below ne…

410-121-0000 Foreword and Definition of Terms (1) The Health Systems Division (Division) Oregon Administrative Rules (OAR) are designed to assist providers in preparing claims for services provided to the Division’s fee-for-service clients. Providers must use Pharmaceutical OARs …

410-121-0021 Organizations Authorized to Provide Pharmaceutical Prescription Services (1) Pharmacies, and Medicare certified independent rural health clinics providing urgent medical services for clients as defined in ORS 414.325(7) may provide drug prescription services for fee-…

410-121-0030 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 …

410-121-0032 Supplemental Rebate Agreements (1) The Division of Medical Assistance Programs (Division) has both a, Centers for Medicare and Medicaid Services (CMS) approved Supplemental Rebate Agreement and a (CMS) approved Value based Agreement. These templates and instructions …

410-121-0033 Polypharmacy Profiling (1) The Division of Medical Assistance Programs may impose prescription drug payment limitations on clients with more than 15 unique fee-for-service drug prescriptions in a six-month period. (2) The Division will review the client’s drug therap…

410-121-0040 Prior Authorization Required for Drugs and Products (1) Prescribing practitioners shall obtain prior authorization (PA) for the drugs and categories of drugs requiring PA in this rule, using the procedures set forth in OAR 410-121-0060. (2) Except as provided in sect…

410-121-0060 How to Get Prior Authorization for Drugs (1) A prescriber electing to order a drug requiring PA may have any licensed medical personnel in their office request the PA. The PA request may be transmitted to the Oregon Pharmacy Help Desk by any of the following methods:…

410-121-0061 Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs) Follow the guidelines in the Durable Medical Equipment and Medical Supplies (OAR 410 Division 122), Home Enteral/Parenteral Nutrition and IV Services (OAR chapte…

410-121-0100 Drug Use Review (1) Drug Use Review (DUR) in Division of Medical Assistance Programs (Division) is a program designed to measure and assess the proper utilization, quality, therapy, medical appropriateness, appropriate selection and cost of prescribed medication thro…

410-121-0111 Pharmacy and Therapeutics Committee (1) The Drug Use Review (DUR)/Pharmacy and Therapeutics Committee (P&T Committee) is composed of 11 individuals appointed by the director of the Oregon Health Authority (Authority) pursuant to ORS 414.353. (2) The P&T Committee sha…

410-121-0135 Pharmacy Management Program (1) The Pharmacy Management Program promotes the appropriate use of quality pharmaceutical services by identifying and correcting overutilization of services. (2) The Pharmacy Management Program limits some fee-for-service clients to recei…

410-121-0143 Client Confidentiality Pharmacists are responsible for maintaining the confidentiality of client information in compliance with HIPAA standards. Facilities shall provide adequate privacy for patient consultations. Statutory/Other Authority: ORS 413.042 Statutes/Other…

410-121-0145 Prescription Requirements (1) Division of Medical Assistance Programs (Division) will make payment for covered drugs supplied on drug order or prescription of a licensed practitioner and dispensed by a pharmacist. Dispensings include new prescriptions, refills of exi…

410-121-0146 Dispensing Limitations (1) The Division of Medical Assistance Programs (Division) shall reimburse the pharmacy for dispensed medication the lesser of: (a) The quantity indicated by the prescriber on the prescription; (b) The quantity indicated by the Division dispens…

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 …

410-121-0148 Dispensing in a Nursing Facility or Community Based Care Living Facility A pharmacy serving Division of Medical Assistance Program’s (Division) clients in a nursing facility or a Community Based Care Living Facility must dispense medication in a manner consistent wit…

410-121-0150 Billing Requirements (1) All 340B covered entities that fill Medicaid patient prescriptions with drugs purchased at the prices authorized under Section 340B of the Public Health Service Act shall bill Medicaid at the actual acquisition cost, plus the entity’s assigne…

410-121-0155 Reimbursement (1) The Division shall pay the lesser of the provider's billed amount or the ingredient cost plus a professional dispensing fee. (2) The ingredient cost is established by the Division as follows: (a) The Oregon Average Actual Acquisition Cost (OR-AAAC) …

410-121-0157 Participation in the Medicaid Drug Rebate Program (1) The Oregon Medicaid Pharmaceutical Services Program is a participant in the Centers for Medicare and Medicaid Services (CMS) Medicaid Drug Rebate Program, created by the Omnibus Budget Reconciliation Act (OBRA) of…

410-121-0160 Dispensing Fees (1) This rule does not apply to IHS and Tribal 638 pharmacies that are reimbursed according to the IHS All-Inclusive Rate (AIR) methodology as described in OAR 410-146-0200. (2) Effective December 1, 2024, professional dispensing fees allowable for se…

410-121-0185 Pharmacy Based Immunization Delivery (1) Pursuant to ORS 689.645 and the Board of Pharmacy administrative rule OAR 855-115-0305, pharmacists may prescribe and administer vaccines to persons ; (a) Who are seven (7) years of age or older; (b) If authorized by the Gover…

410-121-0190 Medication Therapy Management Services and Clozapine Therapy Monitoring (1) Clozapine monitoring protocol requires enhanced record keeping and reporting to the drug manufacturer’s registry in order to dispense the medication. Dispensing pharmacy must meet all drug ma…

410-121-0200 Billing Forms Guidelines for using the Prescription Drug Invoice 1.2 Universal Claim Form. (1) When a paper claim form is needed, this form is used to bill for all pharmacy services, home blood glucose monitors, and related diabetic supplies. These services must be b…

410-121-0220 Instructions for Completion of the Prescription Drug Invoice (1) The 1.2 Universal Claim Form is the required billing form for pharmacies billing on a paper claim. Use the standard instructions for completion of the 1.2 Universal Claim Form. (2) Enter all applicable …

410-121-0280 Billing Quantities, Metric Quantities and Package Sizes (1) Use the actual metric quantity dispensed when billing (up to four decimal places). (2) Use the following units when billing products: (a) Solid substances (e.g., powders, creams, ointments, etc.), bill per G…

410-121-0300 CMS Federal Upper Limits for Drug Payments (1) The Centers for Medicare and Medicaid Services (CMS) Federal Upper Limits for Drug Payments listing of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and 1927(e) of the Act as amended by OBRA 1993 a…

410-121-0420 DESI Less-Than-Effective Drug List (1) An October 23, 1981 ruling by District of Columbia Federal Court directed the Department of Health and Human Services to stop reimbursement, effective October 30, 1981, under Medicaid and Medicare Part B for all DESI less-than-e…

410-121-0580 Oregon Medicaid and Pharmaceutical Manufacturers’ Dispute Resolution Procedures (1) Within 60 days after the end of each calendar quarter, the Division of Medical Assistance Programs (Division) shall report the number of units dispensed for each drug National Drug Co…

410-121-0625 Items Covered in the All-Inclusive Rate for Nursing Facilities (1) The all-inclusive rate for nursing facilities includes but is not limited to various drug products and OTC items. Division requires that nursing facilities be billed for these items. (2) The all-inclu…

410-122-0010 Definitions In addition to the definitions in OAR 410-120-0000, the following definitions in these rules apply: (1) “Activities of Daily Living (ADL's)” means activities related to personal care including, but not limited to, tasks such as eating, toileting, grooming…

410-122-0020 Orders (1) The purchase, rental, or modifications of durable medical equipment and the purchase of supplies must have an order from the prescribing practitioner prior to dispensing items to a client. (2) For any durable medical equipment, prosthetics, orthotics and s…

410-122-0040 Prior Authorization (1) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers shall obtain prior authorization (PA) for Healthcare Common Procedure Coding System (HCPCS) Level II codes as specified in rule, unless otherwise noted. (a) Pro…

410-122-0080 Conditions of Coverage, Limitations, and Restrictions (1) For EPSDT beneficiaries (as defined in OAR 410-151-0001) and clients in the Young Adults with Special Health Care Needs or “YSHCN” program (as defined in OAR 410-200-0455): The EPSDT program covers all medical…

410-122-0090 Face-to-Face Encounter Requirements (for Fee-For-Service Clients) (1) For initial ordering of DME items identified in section (9) of this rule and for those DME items identified as requiring a face-to-face visit in Division 122 rules, an in-person or telehealth face-…

410-122-0180 Healthcare Common Procedure Coding System Level II Coding (1) The Healthcare Common Procedure Coding System (HCPCS) level II is a comprehensive and standardized system that classifies similar products that are medical in nature into categories for the purpose of effi…

410-122-0182 Legend This rule is retroactive and applies to services rendered on or after January 1, 2009. (1) The Division uses abbreviations in the tables within this division. (2) This rule explains the meaning of these abbreviations. (3) PA — Prior authorization (PA): “PA” in…

410-122-0184 Repairs, Servicing, Replacement, Delivery, and Dispensing (1) For indications and limitations of coverage and medical appropriateness, the Division may cover reasonable and necessary repairs, servicing, and replacement of medically appropriate, covered durable medica…

410-122-0186 Payment Methodology (1) Effective October 1, 2024, the Division utilizes a payment methodology for covered durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) that is generally based on the 2024 Medicare fee schedule. (a) The Division fee schedul…

410-122-0188 DMEPOS Rebate Agreements (1) The Health Systems Division has a Centers for Medicare and Medicaid Services (CMS) approved DMEPOS Rebate Agreement. (2) The Division negotiates DMEPOS Rebate Agreements for specific products through the Sovereign States Drug Consortium (…

410-122-0200 Pulse Oximeter for Home Use (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover a tamper-proof (calibrated, preset, and sealed) pulse oximeter for home use when all of the following criteria are met: (A) The client has …

410-122-0202 Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover the initial three (3) month trial period of a positive airway pressure (PAP) device for treatm…

410-122-0203 Oxygen and Oxygen Equipment (1) Indications and limitations of coverage and medical appropriateness: The Division may cover home oxygen therapy services. Refer to Table 122-0203-1 and the following guidelines: (a) For children under age 21 when the treating practitio…

410-122-0204 Nebulizer (1) Indications and limitations of coverage and medical appropriateness: (a) Equipment: (A) Small volume nebulizer: (i) A small volume nebulizer (A7003, A7004, A7005) and related compressor (E0570) may be covered to administer inhalation drugs based on evid…

410-122-0205 Respiratory Assist Devices (1) Indications and limitations of coverage and medical appropriateness: The Division may cover the initial three (3) month trial period of a respiratory assist device (RAD) for clients who are diagnosed with one of the following clinical d…

410-122-0206 Intermittent Positive Pressure Breathing E0500, IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source the Division will rent. Covered if medically appropriate for the following indications: (1) Clients at r…

410-122-0207 Respiratory Supplies Table 122-0207. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.] Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.06…

410-122-0208 Suction Pumps (1) Indications and Limitations of Coverage: (a) Use of a home model respiratory suction pump may be covered for a client who has difficulty raising and clearing secretions secondary to: (A) Cancer or surgery of the throat or mouth; or (B) Dysfunction o…

410-122-0209 Tracheostomy Care Supplies (1) Indications and Coverage: For a client following an open surgical tracheostomy that has been open or is expected to remain open for at least three months: (a) Standard tracheostomy supplies, including tracheostomy tubes (A7520, A7521), …