71st OREGON LEGISLATIVE ASSEMBLY--2001 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 2238
A-Engrossed
House Bill 2497
Ordered by the House June 1
Including House Amendments dated June 1
Sponsored by Representative KRUSE; Representative LEE
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure.
{ - Creates three-year pilot program requiring recipients of
services under Oregon Health Plan to make copayments based on
federal regulations. - }
{ - Prescribes operative dates. - }
{ + Requires practitioner prescribing legend drug for person
receiving medical assistance to write certain information on
prescription. Requires enrollee of medical assistance program who
is enrolling or reenrolling in fee-for-service payment system to
designate primary pharmacy or pharmacy network. Requires
Department of Human Services to adopt rules governing purchase of
legend drugs at pharmacy other than designated primary pharmacy
or pharmacy network and changes in pharmacy or pharmacy network.
Directs Health Services Commission to recommend to Director of
Human Services copayments, not to exceed $5, for purchase of
legend drugs covered under Oregon Health Plan. Requires
Department of Human Services to apply to federal government for
waiver to allow copayments. Directs Department of Human Services
to adopt copayment schedule by rule upon receipt of waiver.
Directs Department of Human Services to take specified actions to
determine amounts of and to collect rebates from pharmaceutical
manufacturers. + }
A BILL FOR AN ACT
Relating to Oregon Health Plan; creating new provisions; and
amending ORS 414.325.
Be It Enacted by the People of the State of Oregon: + }
SECTION 1. ORS 414.325 is amended to read:
414.325. (1) As used in this section { - , - } { + and
sections 2 and 3 of this 2001 Act:
(a) + } 'Legend drug' means any drug requiring a prescription
by a practitioner { - , as defined in ORS 689.005 - } .
{ + (b) 'Pharmacy network' means a group of pharmacies using
a shared database or employing other electronic means to access
prescription information of enrollees from multiple points of
service.
(c) 'Practitioner' has the meaning given that term in ORS
689.005. + }
(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 practitioner's care and within the scope of
practice. Prescriptions shall be dispensed in the generic form
pursuant to ORS 689.515, 689.854 and 689.857 and pursuant to
rules of the { - division - } { + Department of Human
Services + } unless the practitioner prescribes otherwise and an
exception is granted by the { - division - } { +
department + }.
(3) Except as provided in subsections (4) and (5) of this
section, the { - division - } { + department + } shall place
no limit on the type of legend drug that may be prescribed by a
practitioner, but shall pay only for drugs in the generic form
unless an exception has been granted by the { - division - }
{ + department + }.
(4) Notwithstanding subsection (3) of this section, an
exception must be applied for and granted before the
{ - division - } { + department + } is required to pay for
minor tranquilizers and amphetamines and amphetamine derivatives,
as defined by rule of the { - division - } { +
department + }.
(5)(a) Notwithstanding subsections (1) to (4) of this section
and except as provided in paragraph (b) of this subsection, the
{ - division - } { + department + } 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 which the
{ - division - } { + department + } has determined should be
limited to those conditions generally recognized as appropriate
by the medical profession.
(b) The { - division - } { + department + } may not require
prior authorization for therapeutic classes of nonsedating
antihistamines and nasal inhalers, as defined by rule by the
{ - division - } { + department + }, when prescribed by an
allergist for treatment of any of the following conditions, as
described by the Health Services Commission on the funded portion
of its prioritized list of services:
(A) Asthma;
(B) Sinusitis;
(C) Rhinitis; or
(D) Allergies.
{ + (6) When a practitioner prescribes a legend drug under
this chapter, the practitioner shall write on the prescription:
(a) The condition, the diagnosis code for the condition and the
line number of the condition on the prioritized list of services
covered for payment for which the legend drug is being
prescribed; and
(b) The practitioner's Office of Medical Assistance Programs
provider number.
(7)(a) At the time of enrollment or reenrollment in a
fee-for-service payment system, an enrollee shall designate a
primary pharmacy or pharmacy network to dispense legend drugs
covered by the medical assistance program.
(b) The department shall adopt rules establishing procedures
that allow an enrollee to:
(A) Obtain a legend drug at a pharmacy other than a designated
primary pharmacy or pharmacy network; and
(B) Change a designation of a primary pharmacy or pharmacy
network.
(8) The department may not establish or designate a pharmacy or
pharmacy network as exclusive providers of prescription or
pharmacy services for enrollees.
(9) The department shall adopt rules that:
(a) Establish procedures to ensure that a primary pharmacy or
pharmacy network will receive notice when an enrollee obtains a
legend drug at another pharmacy; and
(b) Allow payment at the point of sale to a pharmacy other than
a primary pharmacy or pharmacy network for a legend drug obtained
by an enrollee as described in subsection (7)(b)(A) of this
section. + }
SECTION 2. { + (1) By January 1, 2002, the Health Services
Commission shall recommend to the Director of Human Services a
schedule of copayments, not to exceed $5, to be charged to
enrollees of the Oregon Health Plan for the purchase of legend
drugs covered under the Oregon Health Plan.
(2) The Department of Human Services shall apply to the federal
Health Care Financing Administration to obtain the necessary
waiver from federal regulations to implement the schedule of
copayments recommended by the Health Services Commission.
(3) The department shall report to the President of the Senate,
the Speaker of the House of Representatives and the Legislative
Counsel on whether the waiver required under subsection (2) of
this section was obtained.
(4) Section 3 of this 2001 Act becomes operative on the date of
receipt by the department of the necessary waiver from the
federal Health Care Financing Administration. + }
SECTION 3. { + (1) The Department of Human Services shall
adopt by rule a schedule of copayments recommended by the Health
Services Commission for the purchase of legend drugs by enrollees
of the Oregon Health Plan.
(2) The department may waive the requirement of subsection (1)
of this section upon the request of a fully capitated health plan
or a treating practitioner. + }
SECTION 4. { + The Department of Human Services shall:
(1) Expedite the resolution of rebate disputes between
pharmaceutical manufacturers that participate in the Medicaid
Drug Rebate Program and the department; and
(2) Make significant efforts to adjudicate and collect the
total amount of outstanding balances owed to the department by
pharmaceutical manufacturers for unpaid drug rebates. + }
SECTION 5. { + The Department of Human Services shall enter
into agreements to require manufacturers of generic drugs
prescribed for enrollees of the Oregon Health Plan to provide
rebates of 15.1 percent of the average manufacturer price for the
manufacturer's generic products. The agreements shall require
that if a generic drug manufacturer pays federal rebates for
Medicaid-reimbursed drugs at a level below 15.1 percent, the
manufacturer must provide a supplemental rebate to the department
in the amount necessary to achieve a 15.1 percent rebate
level. + }
SECTION 6. { + (1) As used in this section, 'capitated
services' means those services covered under the Oregon Health
Plan that a contractor agrees to provide for a capitation
payment.
(2) The Department of Human Services shall exclude from
capitated services prescription drugs prescribed for family
planning, mental health and chemical dependency, cancer
treatments, AIDS and HIV-related diseases and transplant
antirejection therapies. + }
SECTION 7. The Department of Human Services shall adopt by rule
a maximum allowable cost for a multiple-source prescription drug
that is available from at least three manufacturers or labelers.
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