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OHP questions and answers - Prescription coverage
Learn about DMAP's policies for fee-for-service pharmacy reimbursement.
 

If you have questions not answered by this page, also see:

For patients enrolled in an OHP coordinated care organization (CCO) or physical health plan, refer to the reimbursement policies of the CCO/plan.

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 OHP-Faqs

 
  
Answer
Which rules tell me about the drugs covered by DMAP?
If a drug is administered by a physician, identified by HCPCS code, coverage is dictated by the Medical Surgical Rules.
 
If a drug in dispensed by pharmacies using an NDC, it is covered by Pharmaceutical Rules. ​
How does DMAP reimburse 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.​

How does DMAP reimburse for drugs dispensed to patients in a long-term care facility or community-based waiver facility?

Certain drugs are part of the facility capitation payments and not reimbursed via drug claim. See Nursing Home List.​

How does DMAP reimburse for mental health drugs?
For all OHP members, DMAP pays for covered mental health drugs on a fee-for-service basis.
  • For the purposes of the above payment policy, "mental health drugs" are defined 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.
Who can DMAP reimburse for drugs?
DMAP only reimburses enrolled pharmacy providers (type 48) for drugs billed by NDC.
 
Other provider types are reimbursed for physician-administered drugs and home enteral nutrition using the professional claim format (CMS-1500 or 837P). ​
How does DMAP reimburse pharmacies for EPIV services?

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.

How does DMAP/OHP determine drug coverage?
To be considered for OHP coverage, drugs must:
  • Have a valid National Drug Code (NDC).
  • Be distributed by a company participating in the Medicaid Drug Rebate Program.
  • Meet DMAP’s prior authorization criteria or be on the Preferred Drug List.
  • Be used for a covered Oregon Health Plan diagnosis. See the Prioritized List.
  • Be used in accord with Pharmacy & Therapeutics Committee recommended criteria.

What drugs does DMAP/OHP never cover?

DMAP does not cover drugs on the DESI List, and does not cover drugs that are used exclusively for not covered diagnoses (e.g., acne drugs).​

How do pharmacies request prior authorization for drugs or 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.

Where can I find the drugs covered by OHP health plans?

You will need to contact the plan. Some plans have their formularies available through Epocrates, where you can also find the Preferred Drug List (listed as "Oregon Medicaid -- open card"). ​

Where can I find information about Medicare Part D coverage?

Visit the DHS Medicare Modernization Act website. This site provides a quick reference for clients, the general public, department staff, policymakers, stakeholders and providers looking for information on the Medicare prescription drug program.

How often does DMAP update the Wholesale Acquisition Cost (WAC) of covered medications?

DMAP updates the price files from First DataBank weekly. The file is downloaded from FDB every Thursday.

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. ​

How does DMAP reimburse pharmacies for drugs?
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).
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. ​