OAR 410-147-0280: Drugs

(1) As defined by the Division of Medical Assistance Programs (Division), a valid Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) encounter excludes pharmaceutical or biologicals not generally provided during a clinic visit. Refer to OAR 41-147-0120 Division Encounter and Recognized Practitioners. (a) Because Division includes the costs of drugs or medication treatments administered by a clinic to treat a client during an office visit in the PPS all-inclusive encounter rate for the office visit, providers cannot bill separately for the costs of the drugs or treatments; (b) Prescriptions are not included in the Prospective Payment System (PPS) encounter rate. To bill for filled prescriptions, the FQHC or RHC’s qualified enrolled pharmacy must bill Division using its pharmacy provider number. (2) Clinics may directly bill Division using their clinic provider number for contraceptive supplies and contraceptive medications only for: (a) Clients enrolled in a prepaid health plan (PHP): Clinics must bill the PHP first. If the PHP will not reimburse for the contraceptive supply or contraceptive medication, then the clinic can bill Division fee-for-service at the clinic’s acquisition cost. See also OAR 410-130-0585, Family Planning Services; (b) Fee-for-service clients: Clinics can directly bill Division fee-for-service at the clinic’s acquisition cost for contraceptive supplies and contraceptive medications. See also OAR 410-130-0585, Family Planning Services. (3) Refer to OAR 410 division 121, Pharmaceutical Services Program Rulebook for specific information.