OAR 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) of the drug; (b) In cases where no OR-AAAC is available, the National Average Drug Acquisition Cost (NADAC); (c) In cases where no OR-AAAC and no NADAC is available, the Wholesale Acquisition Cost (WAC). (3) For ingredient cost for trade name forms of multiple source products: (a) Except as provided in (3)(b) of this rule, the Division shall apply the OR-AAAC or NADAC of the generic form when a trade name form of a multiple source product is dispensed; (b) The Division shall pay the OR-AAAC or NADAC of the trade name form only when the prescribing practitioner certifies the trade version is required or when the brand drug is listed on the Division’s Preferred Drug List. (4) The Division shall revise its OR-AAAC weekly. Pharmacies must make available to the Division or its contractor any information necessary to determine the pharmacy’s actual acquisition cost of drug products dispensed to the Division’s clients. (5) The OR-AAAC shall serve as the basis for reimbursement. Individual pharmacies, other than Indian Health Service, Tribal 638 or Urban Indian Health Program pharmacies, are required to participate in an OR-AAAC survey conducted by the Division or its contractor not more than one time per every 18 to 24-month period. Pharmacies that do not respond to OR-AAAC survey requests may be subject to disenrollment as providers for the Oregon Health Plan. (6) If a provider is unable to purchase a particular drug product at the OR-AAAC, the provider shall report this to the Division or its contractor for further review through a dispute resolution process. Providers may submit inquiries via telephone, facsimile, via electronic mail, or the contractor’s secure web site: https://myersandstauffer.com/client-portal/oregon/: (a) The Division or its contractor shall respond to all inquiries or complaints within 24 hours and resolve the issue within five business days; (b) The pricing dispute resolution process shall include the Division or its contractor verifying the accuracy of pricing to ensure consistency with marketplace pricing and drug availability; (c) Price adjustments shall be made during the next weekly pricing update. (7) The Division restricts claims for hemophilia blood factors to Federally Supported Hemophilia Treatment Centers that are a Center of Excellence, as provided in OAR 410-120-0000.This restriction does not apply to clients with other insurances or Medicare in addition to OHP. The Federally Approved provider of factors, non-factor or gene therapy for people with bleed disorders is the Hemophilia Center at OHSU. Questions concerning bleeding disorder case management shall be directed to this provider by calling: 877-346-0640. (8) No professional dispensing fee is allowed for dispensing pill splitters/cutters or diabetic supplies and glucose monitors. (9) Payment for pill splitters/cutters with a National Drug Code (NDC) number shall be reimbursed at the lesser of the billed amount or the ingredient cost and: (a) A practitioner prescription is required; and (b) The Division shall pay only for one pill splitter/cutter per client in a twelve-month period. (10) A prescription is required for glucose monitors and related diabetic supplies. (11) Payment for glucose monitors and related diabetic supplies billed with an NDC shall be reimbursed at a percentage of Medicare’s rate for the HCPCS procedure code. The Division’s reimbursement rates are listed in the Division’s fee schedule located at: http://www.oregon.gov/OHA/healthplan/pages/feeschedule.aspx.