OAR 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 receiving their prescription drugs through the following sources: (a) A single retail pharmacy to pick up prescriptions; (b) The Division of Medical Assistance Program (Division) mail order pharmacy contractor; and (c) A specialty pharmacy. (3) The Division will not include the following clients in the Pharmacy Management Program: (a) Members enrolled in a Coordinated Care Organization; (b) Clients with Medicare drug coverage in addition to OHP; (c) Children in the care and custody of the Department of Human Services; or (d) Inpatients or residents in a hospital, nursing facility, other medical institution or long term care facility. (4) The Division will consider referrals of potential Pharmacy Management Program clients from the following sources: (a) Providers; (b) Division staff; and (c) Division contractors. (5) Reasons for referring a client to the Division for potential enrollment in the Pharmacy Management Program shall be limited to factors that indicate possible overutilization or drug misuse, or that raise concern for patient safety. Those factors are: (a) Use of three or more pharmacies during the prior six months; (b) Fills prescriptions from more than one prescriber for the same or comparable medications; or (c) Evidence that the client altered a prescription; or (d) Exhibits behaviors or patterns of behavior that the Pharmacy and Therapeutics Committee has identified as indicative of intentional overutilization or misuse. (6) Clients referred to the Division for potential enrollment in the Pharmacy Management Program shall be enrolled in the program only when a licensed pharmacist appointed by the Division conducts a review and concludes the individual utilized pharmaceutical items or services at a frequency or amount that is not medically necessary based on factors including, but not limited to, those described in subsection (5) of this rule. (7) When the Division concludes enrollment in the Pharmacy Management Program is appropriate as described in subsection (6), the Division shall send the client a notice that provides the following information: (a) The Division plans to require that the client use a designated pharmacy for a 12-month period; (b) The specific date when the requirement will begin; (c) An explanation of the reason for enrollment in the Pharmacy Management Program, and the benefits of enrollment in the Pharmacy Management Program; and (d) The client’s right to request the following, within 45 days of the date of the notice: (A) A different designated pharmacy; and (B) An administrative hearing to appeal the Division's decision to enroll the client into the Pharmacy Management Program. (8) Changing the Pharmacy Management Program client’s enrolled pharmacy: (a) Clients may change their enrolled pharmacy if they: (A) Move out of area; (B) Are reapplying for OHP benefits; or (C) Are denied access to pharmacy services by their selected pharmacy for reasons other than the Pharmacy Management Program factors identified by the Division; (b) Clients cannot change their choice of pharmacy more than once every 3 months. (9) Pharmacy Management Program clients may receive drugs from a different pharmacy if the client urgently needs to fill a prescription and the enrolled pharmacy: (a) Is not available; (b) Does not have the prescribed drug in stock; or (c) Is more than 50 miles away from the client’s location at the time the prescription needs to be filled. However, DMAP may deny coverage if the client frequently fills prescriptions out of the area of the enrolled pharmacy. (10) Call the Oregon Pharmacy Help Desk for authorization to fill a prescription in the situations described in (9)(a)–(c) above. (11) The client’s appeal rights and the process for appealing a Division decision to enroll a client in the Pharmacy Management Program are found in OAR 410-120-1860. If the client requests an administrative hearing before the effective date of the client notice and requests that the services be continued, the Authority shall continue the services pursuant to OAR 410-120-1865.