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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-121-0030-11152016NewNotice of Rulemaking Hearing
410-121-0030
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.
11/15/2016
Nprm-121-0040-10182016Notice of Rulemaking Hearing
410-121-0040
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.
10/18/2016
121-0030-10012016NewTemporary Rule Filing
410-121-0030
Amending PDL March 31, May 26, 2016, DUR/P&T Action
10/1/2016
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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.

  
  
121rb0826168/26/2016
121rb0701167/1/2016
121rb0628166/28/2016
121rb0501165/1/2016
121rb0212162/12/2016
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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​

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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

  
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, 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
Oregon Medicaid PA Criteria, January 20161/1/2016
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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 - 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
Oregon Medicaid Preferred Drug List - October 1, 201510/1/2015
1 - 5Next

7-11 Drug Carve Out List

  
  
7-11 Drug Carveout List, July 20167/22/2016
7-11 Drug Carveout List, March 20163/29/2016
7-11 Drug Carveout List, February 20142/18/2014
7-11 Drug Carveout List, November 201311/5/2013
7-11 Drug Carveout List, October 201310/7/2013
1 - 5Next
 

Forms

​​​
  
Description
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. ​​​​​​​​​​​​​​​​​​​​​​

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Pharmacy program announcements

​​​
  
  
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

Who to call for help


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