OAR 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 services shall be reimbursed as follows: (a) All 340B pharmacies operated by a 340B covered entity shall be reimbursed at a rate of $20.86 per claim; (b) Except as described in OAR 410-121-0160(2)(c), all other enrolled pharmacies shall be reimbursed based on the individual pharmacy’s annual claims volume as follows: (A) Less than 40,000 claims a year (“lowest volume tier”) = $16.87; (B) Between 40,000 and 79,999 claims per year = $11.93; (C) 80,000 or more claims per year (“highest volume tier”) = $9.99 (c) Critical Access Pharmacy (CAP) as defined in OAR 431-121-2000(4) shall be reimbursed at the lowest volume tier regardless of volume. The Division shall apply the CAP designation according to the most recently posted quarterly assessment. (3) All Division enrolled pharmacies subject to this rule shall be required to complete an annual survey that collects claim volumes from enrolled pharmacies and other information from the previous twelve (12) month period to determine the appropriate dispensing fee reimbursement: (a) Claims volume shall be stated by total Oregon Health Plan (OHP) covered prescriptions and claims from all payer types; (b) Survey activities shall be conducted by either the Division or its contractor and must be completed and returned by pharmacies within fourteen (14) days of receipt; (c) Completed surveys must be signed with a letter of attestation by the store owner or majority owner; (d) Pharmacies other than IHS or Tribal pharmacies, that fail to respond to the survey or do not include the letter of attestation shall default to the highest volume tier; (e) Once a volume-based tier is established for a calendar year, the pharmacy’s dispensing fee shall remain in that tier until the next annual claims volume survey is conducted; (f) Newly enrolled 340B pharmacies shall be reimbursed at a rate of $20.86 per claim. All other pharmacies shall be defaulted to the highest volume tier until the next claims volume survey is conducted. [Publications referenced are available from the agency.]