CurrentOklahoma Health Care AuthorityPolicy N/A

Amount, Duration and Scope of Medical and Remedial Care and Services Provided Categorically Needy

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This document governs the amount, duration, and scope of prescribed drug services for categorically needy Oklahoma Medicaid recipients, including the tiered drug list, prior authorization framework, and supplemental rebate policies.

Policy Summary

PayerOklahoma Health Care Authority

PolicyAmount, Duration and Scope of Medical and Remedial Care and Services Provided Categorically Needy

Policy CodePolicy N/A

Change TypeRevised supplemental rebate provisions

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionSubmit prior authorization requests for drugs not included in Tier One under the Oklahoma tiered drug list process.

SourceLink

POLICY UPDATE CHANGES

The supplemental rebate provisions were updated to recognize the revised Sovereign States Drug Consortium agreement authorized by CMS.

Tier OnePreferred tier generally available without additional documentation

2017Oklahoma joined the Sovereign States Drug Consortium

Section 1927Federal statutory authority for supplemental rebates

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CurrentOklahoma Health Care AuthorityPolicy N/A

Amount, Duration and Scope of Medical and Remedial Care and Services Provided Categorically Needy

Customize your policy alerts

Sign up for all Oklahoma Health Care Authority policy alerts

Know when Oklahoma Health Care Authority releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerOklahoma Health Care Authority

PolicyAmount, Duration and Scope of Medical and Remedial Care and Services Provided Categorically Needy

Policy CodePolicy N/A

Change TypeRevised supplemental rebate provisions

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionSubmit prior authorization requests for drugs not included in Tier One under the Oklahoma tiered drug list process.

SourceLink

POLICY UPDATE CHANGES

The supplemental rebate provisions were updated to recognize the revised Sovereign States Drug Consortium agreement authorized by CMS.

Tier OnePreferred tier generally available without additional documentation

2017Oklahoma joined the Sovereign States Drug Consortium

Section 1927Federal statutory authority for supplemental rebates

Non-Tier-One Drug Authorization

Non-Tier-One drug authorization

Prior authorization criteria are established by the DUR Board for drugs covered under the Oklahoma tiered drug list.

Prior authorization pathway: The requested drug is not included in Tier One, and the DUR Board's medical-necessity criteria for the drug are satisfied.

The DUR Board establishes the applicable criteria for the prior authorization process; individual drug-specific criteria are not specified in this document.

Tiered Drug List Authorization Requirements

Prior Authorization

Tiered Drug List Prior Authorization

The DUR Board determines medical necessity for drugs covered under the Oklahoma tiered drug list and establishes criteria for the prior authorization process.

Prior Authorization

Non-Tier-One Product

Drugs not included in Tier One are subject to the Oklahoma tiered drug list prior authorization process. Tier One preferred products are generally available without additional documentation.

Policy Summary

PayerOklahoma Health Care Authority

PolicyAmount, Duration and Scope of Medical and Remedial Care and Services Provided Categorically Needy

Policy CodePolicy N/A

Change TypeRevised supplemental rebate provisions

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionSubmit prior authorization requests for drugs not included in Tier One under the Oklahoma tiered drug list process.

SourceLink

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