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Pharmaceutical Services Program

Pharmaceutical Services Program

Find Oregon Administrative Rules and supplemental information administered by the Health Systems Division.

Recent rule filings

You can sort or filter by document type or effective date. You can also view Pharmaceutical Services Program rules as filed with the Secretary of State (please note that rules filed by the first of the month will not be posted on the Secretary of State website until the middle of the filing month).

File Description
Nprm-121-0030-11152016Notice of Rulemaking Hearing
Amending PDL March 31, May 26, 2016 DUR/P&T Action
Rulemaking Hearing: November 15, 2016, 10:30 a.m., Room 160
Last Opportunity for Public Comment: November 17, 2016, by 5 p.m.
Send Comments to: hsd.rules@state.or.us.
Nprm-120-0040-11152016Notice of Rulemaking Hearing
Amending Prior Authorization Approval Criteria Guide
Rulemaking Hearing: November 15, 2016, 10:30 a.m., Room 160
Last opportunity for public comment: November 17, 2016, 5 p.m.
Send comments to: hsd.rules@state.or.us.
Nprm-121-0040-10182016Notice of Rulemaking Hearing
Amending Prior Authorization Approval Criteria Guide
Rulemaking Hearing: October 18, 2016, 10:30 a.m., Room 137D
Last Opportunity for Public Comment: October 20, 2016, by 5 p.m.
Send Comments to: hsd.rules@state.or.us.
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Administrative rulebooks

Each rulebook is an interactive PDF that contains all program rules effective on the "Effective Date" listed for the rulebook.

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Supplemental information and guidelines

Also see our frequently asked questions about OHP fee-for-service prescription coverage and Oregon Medicaid Pharmacy Quick Reference.

For resources provided by the OSU College of Pharmacy's Drug Use Review and Management (DURM) Program, including the Oregon State Drug Review, visit the DURM website.

Supplemental rebate information

Model Supplemental Rebate Agreement
Federal approval - January 2011
Facts about managed care organization drug rebates
W-9 form for drug rebate reporting

340B resources​

340B Claims File Instructions and Design
340b Claims Response File Design
340B Entities Q1 2016
340B state policy
340B Supplemental Chart

Provider guides

Claim Adjustment Handbook
Pharmaceutical Services Provider Guide, May 25, 2016
Pharmacy Billing Instructions
Prior Authorization Handbook
OHP birth control methods and reimbursement

Billing diabetic supplies

Diabetic Supply Codes and Fees - Billing Examples, August 2011
National Drug Codes for Diabetic Supplies

Other resources

CCO Pharmacy Benefit Managers
Drugs included in the bundled rate for long-term care nursing facilities
CMS Fact Sheet - Tamper-Resistant Prescription Pad Law
NCPDP D.0 Payer Sheet

Oregon Medicaid PA Criteria

If you want to view criteria older than the last 5 versions, click "Effective Date" to select the PA criteria by effective date.

Oregon Medicaid PA Criteria, October 201610/13/2016
Oregon Medicaid PA Criteria, August 20168/25/2016
Oregon Medicaid PA Criteria, July 20167/1/2016
Oregon Medicaid PA Criteria, May 20165/1/2016
Oregon Medicaid PA Criteria, February 20162/12/2016
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Preferred Drug List

Physical health drugs on this list do not require PA. Access the list using Epocrates Rx ("Oregon Medicaid - open card"), and access formularies for other payers, including OHP health plans. Lists before 2012 are in the administrative rulebooks.

Oregon Medicaid Preferred Drug List - October 1, 201610/1/2016
Oregon Medicaid Preferred Drug List - July 1, 20167/1/2016
Oregon Medicaid Preferred Drug List - May 1, 20165/1/2016
Oregon Medicaid Preferred Drug List - January 1, 20161/1/2016
Oregon Medicaid Preferred Drug List - November 1, 201511/1/2015
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7-11 Drug Carve Out List

7-11 Drug Carveout List, Third Quarter 201610/1/2016
7-11 Drug Carveout List, Second Quarter 20167/22/2016
7-11 Drug Carveout List, First Quarter 20163/29/2016
7-11 Drug Carveout List, February 20142/18/2014
7-11 Drug Carveout List, November 201311/5/2013
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OHP 3978
Prior Authorization Request for Pharmacy and Oral Nutritional Supplements

Other pharmacy links

Actual Average Acquisition Cost (AAAC) rates

About AAAC rates
Weekly Rate Updates and AAAC rate review forms and processes

Non-Medicaid pharmacy programs

OHA pharmacy meetings

CCO Pharmacy Directors
Pharmacy and Therapeutics Committee

Centers for Medicare and Medicaid Services

CMS Federal Upper Limits - CMS has published cumulative changes from 2002 through September 25, 2009 under "Changes made to Transmittal No. 37."
Medicaid Drug Rebate Program data files - Less-Than-Effective (LTE/IRS) drugs have a DESI indicator of 5 or 6.
Medicaid Drug Rebate List Updates

Other links

Evidence-based reports

Sovereign States Drug Consortium (SSDC) website
Medicare Modernization Act (MMA) website
National Provider Identifier look-up - All pharmacy claims should include the NPI of the prescribing provider in the prescriber ID field. ​​​​​​​​​​​​​​​​​​​​​​

Pharmacy program announcements
Flucelvax QIV code 90674 now open for fee-for-service billing effective August 1, 201610/11/2016
Hospital Presumptive Eligiblity for OHP Pharmacies9/23/2016
Fee-for-service coverage of botulinum toxins now requires prior authorization7/29/2016
Point of Sale downtime planned for July 2-4, 20166/17/2016
Change to Benzodiazepine PA Criteria effective July 1, 20166/10/2016
Filling prescriptions for Oregon Medicaid clients who are not in the Oregon MMIS Point of Sale system11/14/2014
October 2014 PDL and prior authorization criteria updates10/23/2014
Encounter reporting of 340B-eligible drugs dispensed to Oregon Health Plan (OHP) clients10/16/2014
August-September 2014 PDL and prior authorization criteria updates9/17/2014
Preferred Drug List and prior authorization criteria updates effective July 15, 20147/16/2014
Information about Hospital Presumptive Eligibility (HPE) for OHP pharmacies5/23/2014
March 21, 2014 Preferred Drug List (PDL) and PA Criteria updates3/28/2014
Fee-for-service Preferred Drug List update effective January 10, 20141/13/2014
Fee-for-service Preferred Drug List and prior authorization criteria updates effective January 1, 20141/3/2014
Preferred Drug List and PA criteria updates effective May 1, 20134/29/2013
Preferred Drug List (PDL) and prior authorization criteria updates effective Jan. 1, 201312/21/2012
Dec. 31 and Jan. 1 Point of Sale billing changes12/19/2012
Updated Coordinated Care Organization Pharmacy Benefit Manager List11/6/2012
Oregon Pharmacy Call Center closed due to Hurricane Sandy; please leave voicemails at 1-888-202-2126 for same-day response10/29/2012
Wave 4 Coordinated Care Organization (CCO) transition update10/29/2012
Preferred Drug List and prior authorization criteria updates effective September 24, 20129/13/2012
Brand GEODON® and LEXAPRO® to be removed from the OHP Preferred Drug List8/22/2012
Please call the Oregon Pharmacy Call Center for help filling any Oregon Health Plan prescriptions during CCO transition8/1/2012
Preferred Drug List and PA criteria updates effective July 23, 20127/18/2012
Lipitor® no longer on OHP preferred drug list7/12/2012
Preferred Drug List and PA criteria updates effective June 21, 20126/15/2012
May 14, 2012 PDL and prior authorization criteria updates5/14/2012
Zyprexa® no longer preferred over generic equivalents starting May 165/8/2012
Changes to LEXAPRO®, ZYPREXA® and GEODON® until further notice4/24/2012
How to adjust point of sale claims submitted before Jan. 1, 20121/13/2012
LOVENOX® added to OHP’s Preferred Drug List, effective January 1, 201212/27/2011
Pharmaceutical Services Program changes effective January 1, 201212/20/2011
DMAP will only accept NCPDP D.0 Point of Sale claims beginning Jan. 1, 201212/6/2011
Pharmaceutical Services rule revisions effective September 1, 20119/1/2011
Usual and Customary charge definition revised, effective September 1, 20118/22/2011
Aug. 1 Diabetic Supply Billing Updates7/29/2011
Bill diabetic supplies in pharmacy claim format starting August 1, 20117/18/2011
Adjustments for HFA inhaler overpayments now scheduled for July 23 weekend7/12/2011
Fee-for-service rate reduction for pharmacy services effective August 1, 20117/8/2011
Pharmacies can bill for diabetic supplies starting August 1, 20116/20/2011
System mass adjustments planned for overpayments of certain inhalers6/15/2011
NCPDP D.0 claims submission changes and transition testing5/13/2011
Compounded 17aHPC is only covered as physician-administered drug4/21/2011
Coverage for certain compounding ingredients ends April 1, 20113/25/2011
Certain products removed from Preferred Drug List effective March 1, 20112/24/2011
New Third-Party Liability edit and NCPDP D.0 update2/24/2011
DMAP now uses Average Actual Acquisition Cost Reimbursement1/5/2011

Who to call for help