About OHP prescription drug coverage
Pharmacies that enroll as Oregon Medicaid providers with the Oregon Health Authority (OHA) can bill OHA for:
- Prescriptions dispensed to Oregon Health Plan (OHP) members not enrolled in a coordinated care organization (CCO), and
- For all OHP members, certain mental health drugs not covered by CCOs.
The Oregon Medicaid Preferred Drug List, Oregon's Prioritized List of Health Services, and the federal Medicaid Drug Rebate Program determine OHA prescription coverage.
All other prescriptions are billed to CCOs. CCOs provide medical and prescription drug coverage to over 90 percent of OHP members statewide. Their coverage policies may differ from OHA's, but they must follow Prioritized List coverage.
For more information, see our Frequently asked questions about OHP prescription coverage.
For information about prescription coverage for CCO members, contact the CCO.
Information for providers
The Pharmaceutical Services program guidelines (Oregon Administrative Rules Chapter 410, Division 121) contain the billing and payment policies for enrolled pharmacies to follow when they need to bill OHA instead of a CCO/plan.
Recent rule filings, rulebooks and supplemental information - Eligibility and coverage information; billing guidelines; Point of Sale, ProDUR and prior authorization information; 340B program information; contact information; information for prescribers, including PA criteria, Drug Utilization Review information, and Preferred Drug List information related forms and resources.
Oregon Medicaid Pharmacy Quick Reference - Telephone numbers, e-mail addresses, Web links, quick facts about billing Oregon Medicaid, and after-hours contact information for CCO/plan prescriptions.
Average Actual Acquisition Cost (AAAC) methodology - Starting Jan. 1, 2011, Oregon Medicaid's pharmacy program was the first in Oregon to adopt this rate methodology.
Epocrates Rx - Use this free mobile drug reference to get point-of-care access to the Oregon Medicaid Preferred Drug List and the formularies for most CCOs.
Learn how to become an OHP provider.
Information for members
People with OHP Plus, OHP with Limited Drug, and CAWEM Plus benefits receive prescription drug coverage.
Prescription drugs are an important part of keeping a patient healthy and preventing and treating illness. OHP uses evidence-based research to prepare a preferred drug list for members; managed care plans in Oregon use a similar list. As an OHP member, you have a right to access prescription drugs that you and your doctor decide are necessary for your health. If you have any questions about this, please call one of the telephone numbers listed below.
OHP provides prescription drugs to all members through one of three methods:
- If an OHP member is a Fee-for-Service (FFS) member, all mental and physical health drugs are provided through the state. For all questions about access to necessary prescription drugs, please contact OHP Client Services: 1-800-273-0557.
- If an OHP member is enrolled in a CCO for medical care, all physical health drugs are provided through the CCO/plan. For questions about all non-mental health drugs, please contact your CCO/plan directly (use the number listed on your member ID or coverage letter).
- If an OHP member is enrolled in a CCO for medical care, all mental health drugs are provided through the state. For questions, please contact OHP Client Services: 1-800-273-0557.
Your doctor will know what prescriptions are covered, and your pharmacy will know whether you will need to pay a copayment. FFS members with can also choose to enroll with OHP's home-delivery pharmacy service and pay no copayments for home-delivered drugs (CCOs and plans may offer a similar service to their members).
Mental health prescription drugs
For more information, see this list of mental health drugs