OAR 410-121-0146: Dispensing Limitations

(1) The Authority 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 Authority’s dispensing limitations as outlined in this rule; or (c) The quantity needed for Prescription Synchronization. (2) The pharmacy may only dispense less than the prescribed quantity when the prescribed quantity exceeds the Authority’s dispensing limitations, or when a lesser quantity is needed for Prescription Synchronization. (3) The pharmacy may, at the member’s direction, dispense less than the prescribed quantity of a maintenance medication in order to align the refill dates if the member has received the same dose for two months or more. (4) Unless otherwise specified in this rule, the Authority shall not reimburse claims for medications exceeding a 34-day supply. (5) All pharmacy providers shall be reimbursed for up to a 100-day supply of preferred drugs in the following Standard Therapeutic Classes of medications: (a) Ataractics, Tranquilizers — 07; (b) Psychostimulants, Antidepressants — 11; (6) Exceptions to the 34-day supply do not apply to claims for the following Standard Therapeutic Classes of medications. Claims exceeding a 34-day supply for these medications shall not be reimbursed under any circumstances: (a) Muscle Relaxants — 08; (b) CNS Stimulants — 10; (c) Amphetamine Preps — 12; (d) Narcotic Analgesics — 40; (e) Sedative Barbiturate — 46; (f) Sedative Non-Barbiturate — 47. (7) The Authority may reimburse for more than a 34-day supply if the medication’s original package size cannot be divided or when primary insurance (third party liability) pays for a larger day supply. (8) Except for medications listed in subsections (5) and (6) of this rule, claims for up to a 100-day supply of the following types of medications may be reimbursed to the Authority’s mail order pharmacy contractor, Indian Health mail order pharmacy providers, and 340B providers: (a) A PDL generic; and (b) A generic drug not on the PDL, costing $10 per month or less. (9) All pharmacy providers shall be reimbursed for up to a 365-day supply of family planning drugs. (10) Notwithstanding subsection (4) and subsection (11) of this rule, the Authority shall reimburse all pharmacy providers for up to a 365‑day supply of preferred drugs within the following Standard Therapeutic Classes, provided that the specific drug dispensed can be stored at room temperature. This subsection is a standalone exception to the day supply limitations in subsections (5), (7), and (8). If the medication is a controlled substance, reimbursement is limited to the maximum day supply permitted under state and federal law. The applicable Standard Therapeutic Classes are: (a) Estrogen — Standard Therapeutic Class 61 (b) Progesterone — Standard Therapeutic Class 62 (c) Aldosterone antagonists - Standard Therapeutic Class 53 (d) Androgens - Standard Therapeutic Class 60 (e) Gonadotropin-releasing hormone (GNRH) agonists – Specific Therapeutic Classes P1M, P1P, V1O. (11) Selected medications identified by the Authority shall be limited to a 15-day supply for initial fills. The Authority has identified these medications as having high side effect profiles, high discontinuation rates, or requiring frequent dose adjustments. (12) The pharmacy should provide a minimum of a one-month supply of insulin per dispensing once diabetes management has been stabilized. (13) For vaccines available in multiple dose packaging, the Division shall allow a dispensing fee for each multiple dose. When vaccines are administered at the pharmacy, refer to Oregon Administrative Rule (OAR) 410-121-0185. (14) Splitting prescriptions: (a) For compounded prescriptions, pharmacy providers must bill components of the prescription separately. (b) When a pharmacy provider receives third party payments for compounded prescriptions, the payments must be split and applied equally to each component; (c) The Authority shall consider any other form of prescription splitting as a billing offense and take appropriate action as described in the General Rules (OAR 410 division 120).