ORS Chapter 414 — Medical Assistance

ORS 414.325. (1) As used in this section: (a) Legend drug means any drug requiring a prescription by a practitioner, as defined in ORS 689.005. (b) Urgent medical condition means a medical condition that arises suddenly, is not life-threatening and requires prompt treatment to avoid the development of more serious medical problems. (2) A licensed practitioner may prescribe such drugs under this chapter as the practitioner in the exercise of professional judgment considers appropriate for the diagnosis or treatment of the patient in the practitioners care and within the scope of practice. Prescriptions shall be dispensed in the generic form pursuant to ORS 689.515 and pursuant to rules of the Oregon Health Authority unless the practitioner prescribes otherwise and an exception is granted by the authority. (3) Except as provided in subsections (4) and (5) of this section, the authority shall place no limit on the type of legend drug that may be prescribed by a practitioner, but the authority shall pay only for drugs in the generic form unless an exception has been granted by the authority. (4) Notwithstanding subsection (3) of this section, an exception must be applied for and granted before the authority is required to pay for minor tranquilizers and amphetamines and amphetamine derivatives, as defined by rule of the authority. (5)(a) Notwithstanding subsections (1) to (4) of this section and except as provided in paragraph (b) of this subsection, the authority is authorized to: (A) Withhold payment for a legend drug when federal financial participation is not available; and (B) Require prior authorization of payment for drugs that the authority has determined should be limited to those conditions generally recognized as appropriate by the medical profession. (b) The authority may not require prior authorization for: (A) Therapeutic classes of nonsedating antihistamines and nasal inhalers, as defined by rule by the authority, when prescribed by an allergist for treatment of any of the following conditions, as described by the Health Evidence Review Commission on the funded portion of its prioritized list of services: (i) Asthma; (ii) Sinusitis; (iii) Rhinitis; or (iv) Allergies. (B) Any mental health drug prescribed for a medical assistance recipient if: (i) The claims history available to the authority shows that the recipient has been in a course of treatment with the drug during the preceding 365-day period; or (ii) The prescriber specifies on the prescription dispense as written or includes the notation D.A.W. or words of similar meaning. (6) The authority shall pay a rural health clinic for a legend drug prescribed and dispensed under this chapter by a licensed practitioner at the rural health clinic for an urgent medical condition if: (a) There is not a pharmacy within 15 miles of the clinic; (b) The prescription is dispensed for a patient outside of the normal business hours of any pharmacy within 15 miles of the clinic; or (c) No pharmacy within 15 miles of the clinic dispenses legend drugs under this chapter. (7) Notwithstanding ORS 414.334, the authority may conduct prospective drug utilization review in accordance with ORS 414.351 to 414.414. (8) Notwithstanding subsection (3) of this section, the authority may pay a pharmacy for a particular brand name drug rather than the generic version of the drug after notifying the pharmacy that the cost of the particular brand name drug, after receiving discounted prices and rebates, is equal to or less than the cost of the generic version of the drug. (9)(a) Within 180 days after the United States patent expires on an immunosuppressant drug used in connection with an organ transplant, the authority shall determine whether the drug is a narrow therapeutic index drug. (b) As used in this subsection, narrow therapeutic index drug means a drug that has a narrow range in blood concentrations between efficacy and toxicity and requires therapeutic drug concentration or pharmacodynamic monitoring.