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Oregon Health Plan
Oregon Health Plan

Frequently asked questions: DMAP prescription coverage

 

This page provides information about DMAP's policies for fee-for-service pharmacy reimbursement.

If you have questions not answered by this page, refer to DMAP's pharmacy rulebook and supplemental information, which contain the rules and procedures for DMAP claim submissions. For patients enrolled in OHP managed care plans, refer to the reimbursement policies of the individual's plan.

 

Q: Does DMAP/OHP cover [a particular] drug?
A: If a drug is administered by a physician, identified by J-code, HCPCS, coverage is dictated by the Medical Surgical Rules. If a drug in dispensed by pharmacies using an NDC, it is covered by Pharmaceutical Rules.
  • NDCs must be added to the First DataBank drug file and then loaded to the PBM claim processing system. Upon market release, there may be a one week delay to add new NDCs to First DataBank and another week for loading them to the PBM.
  • Some OTC products do not have a valid NDC number assigned. A pharmacy will get a "non-matched NDC" error. Often these products are classed as nutritional supplements and not as drugs by the FDA. The product ID on the package could be a UPC or other identifying number, but it is not an NDC if it is not listed in First DataBank. DMAP cannot cover products that do not have a valid NDC listed in First DataBank. The pharmacy may have another product on shelf that has a valid NDC that DMAP does cover.
  • Drugs must be distributed by a company participating in the Medicaid Drug Rebate Program. See Medicaid Rebate List.
  • Drugs must NOT be on the DESI List.
  • Some drugs that are used exclusively for not covered diagnoses are excluded from coverage (e.g. acne drugs).
  • Any physical health drugs not listed on the Preferred Drug List (Practitioner-Managed Prescription Drug Plan) require prior authorization. See new drugs in PDL classes. Any changes to this rule follow a standard Oregon Administrative Rulemaking process. You can sign up for notification of proposed rules changes.
    • Coverage is also listed in Epocrates, a free formulary hosting service. This is updated approximately weekly.
    • Drugs must be used for a covered Oregon Health Plan diagnosis. See the Prioritized List.
    • -AND-
    • Drugs must be used in accord with Pharmacy & Therapeutics Committee recommended criteria for use.
  • DMAP also has a voluntary mental health PDL. Non-preferred drugs from the Preferred Drug List are not restricted unless they meet criteria listed above (e.g., require PA, are for not-covered conditions, etc.).
Q: Where can I find the formulary list for OHP managed care plans?
A: You will need to contact the managed care plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). Quick lists of plan addresses and telephone numbers are available at this link.
Q: What are the copayment requirements for OHP clients?
A: OHP Plus (BMH) and OHP with Limited Drug (BMM, BMD) clients have copayments. For more information, see the Frequently Asked Questions about Copayments.

 


Q: What is the Preferred Drug List (PDL)? 
A: During the 2001 Oregon Legislative session, Senate Bill 819 created the Practitioner-Managed Prescription Drug Plan (PMPDP). The PMPDP requires the Oregon Health Plan (OHP) to maintain a list of the most cost-effective drugs to prescribe for fee-for-service clients. This list is called the Preferred Drug List (PDL).
  • New prescriptions for non-preferred physical health drugs (not listed on the physical health PDL) require prior authorization (PA)
  • Non-preferred mental health drugs do not require PA.
  • All non-preferred prescriptions are subject to OHP Plus (BMM, BMH, BMD) copayments when applicable
Q: Who created the PDL? 
A: Local doctors, pharmacists, nurse practitioners and consumers recommended drugs from selected classes for the PDL. The Health Resources Commission (HRC) worked with the Oregon Health and Science University's Center for Evidence-Based Policy to gather clinical data, as well as information from pharmaceutical manufacturers and public testimony. They evaluated all information according to established evidence methods and in a public forum. The HRC submitted recommendations to DMAP for pricing and DMAP made cost-effective selections, creating the PDL.
Q: Why do we have a PDL? 
A: The PDL identifies the most effective and safe drugs for the majority of patients, based on the information available. Oregon researchers and experts have carefully considered the comparative safety and effectiveness of the drugs recommended for inclusion on this list. Of the drugs recommended, only those representing the best value to the OHP are included.
Q: How do I use the PDL? 
A: The PDL is a tool to identify the most cost-effective drugs for open-card OHP patients. DMAP asks that when practitioners start a new drug, to consider the drugs on the PDL first.
Q: Where can I find the Preferred Drug List (PDL)? 
A: You can:
Q: How do I get on the PDL?
A: The list is updated in January and July. Drug manufacturers who want to propose drugs for PDL consideration can learn more at the Supplemental Rebate Agreements page.
Q: When is the next Pharmacy & Therapeutics Committee meeting? How can I get notified of future meetings?
A: See Pharmacy & Therapeutics Committee meeting notices. You can also sign up for e-notification of meetings posted to this page. Additional information is archived.

 


Q: How often does DMAP update the Whole Acquisition Cost (WAC) of covered medications?
A: DMAP updates the price files from First DataBank weekly. The file is downloaded from FDB every Thursday.
Q: How does DMAP reimburse pharmacies for drugs?
A: Federal Medicaid law requires that services and products provided to Medicaid clients are reimbursed at Estimated Acquisition Cost (EAC). Effective Jan. 1, 2011, drugs dispensed by retail pharmacies are reimbursed at the lower of:
  • Usual and Customary (U/C) or billed amount;
  • Average Actual Acquisition Cost (AAAC). Whole Acquisition Cost (WAC) will apply in cases where no AAAC cost is available; or
  • Federal Upper Limit (FUL).

Patient copayments are deducted from reimbursement.

 

Professional dispensing fees for allowable services are based on pharmacy claim values as follows:

  • Less than 29,999 claims a year = $14.01;
  • Between 30,000 and 49,999 claims per year = $10.14;
  • 50,000 or more claims per year = $9.68.

For compound drugs: Each component of a compound prescription, as defined in OAR 410-121-0146 (7) and 410-121-0160 (3) must be billed separately and is paid as above, but with a single dispensing fee. Any reimbursement received from a third party for compounded prescriptions must be split and applied equally to each component.

 

For clients in a long-term care facility or community-based waiver facility and served by a qualified pharmacy: Certain drugs are part of the facility capitation payments and not reimbursed via drug claim. See Nursing Home List.

 

For mental health drugs: These drugs are "carved-out" of the all OHP managed care contracts. This means that for all OHP clients (those enrolled in managed care and those who are not) mental health drugs are paid for on a fee-for-service basis

 

For the purposes of the above payment policy, "mental health drugs" are defined in the managed care contracts as those drugs classified by First DataBank in the Standard Therapeutic Class equal to Class 07 (Ataractics, Tranquilizers), Class 11 (Psychostimulants, Antidepressants). In addition, lamotrigine and divalproate are also considered mental health drugs.

Q: Who can DMAP reimburse for drugs?
A: DMAP only reimburses enrolled pharmacy providers (type 48) for drugs billed by NDC. Pharmacies can bill for drugs in the following formats:
  • Point of Sale (electronic billing by a pharmacy)
  • Paper (NCPDP Universal Claim Form 5.1 -- Used for all pharmacy services except DME and home enteral/pareteral nutrition and IV services identified with a 5-digit HCPCS)
  • Pharmacy Web Claim (through the Provider Web Portal).

DMAP currently does not reimburse DME providers (type 36) who bill DMAP for drugs using the professional claim format (CMS-1500 or 837P). Please refer to EPIV provider guidelines for services billed by a DME provider type.

 

If a drug is administered by a physician, identified by J-code, HCPCS, coverage is dictated by the Medical Surgical Rules. If a drug is dispensed by pharmacies using an NDC, it is covered by Pharmaceutical rules.

Q: How does DMAP reimburse pharmacies for EPIV services?
A: Pharmacies can bill DMAP for oral nutritional supplements using the pharmacy claim format (Point of Sale or UCF 5.1) only when the supplement has a valid NDC. Prior authorization is required for all oral nutritional supplements:
  • To request PA, complete the DMAP 3978 form and fax to the Oregon Pharmacy Call Center at 888-346-0178
  • Or call the Oregon Pharmacy Call Center at 888-202-2126 with the diagnosis code and your NPI.

Nutritional formula administered by enteral tube is not available for billing through Point of Sale.

  • Only enrolled DME providers (type 36 -- Miscellaneous Medical Provider) can bill for these items using the professional claim format (CMS-1500 or 837P.
  • For more information about billing for home enteral nutritional services, refer to OAR 410-148-0260 -- Home Enteral Nutrition in the EPIV provider guidelines.
 

Page updated: March 19, 2012