Okla. Admin. Code § 317:30-5-42.20

Current through Vol. 42, No. 3, October 15, 2024

Section 317:30-5-42.20 - High-investment drugs - outpatient hospitals

(a) The Oklahoma Health Care Authority (OHCA) designates certain high-investment drugs to be reimbursed separately pursuant to the Oklahoma Medicaid State Plan for members receiving services at an outpatient hospital.

(b) The list of OHCA-designated high-investment drugs is set forth on the Pharmacy page of the OHCA website, which is available at https://okhca.org. This list may be updated as deemed necessary.

(c) All high-investment drugs require prior authorization [refer to Oklahoma Administrative Code (OAC) 317:30-3-31] , and the outpatient hospital stay continues to be subject to applicable medical necessity criteria requirements [refer to OAC 317:30-3-1(f)] .

(d) OHCA-designated high-investment drugs provided to eligible members, when treated in out-of-state outpatient hospitals, may be reimbursed in the same manner as in-state hospitals. Out-of-state outpatient hospitals must meet applicable out-of-state conditions of payment set forth in OAC 317:30-3-89 through 317:30-3-92, and in the Oklahoma Medicaid State Plan.

Okla. Admin. Code § 317:30-5-42.20

Adopted by Oklahoma Register, Volume 37, Issue 19, June 15, 2020, eff. 5/14/2020

Adopted by Oklahoma Register, Volume 38, Issue 23, August 16, 2021, eff. 9/1/2021