About OHP prescription drug coverage
This page provides information about Oregon Health Plan (OHP) prescription coverage for pharmacies, prescribers and OHP members. For information about prescription coverage for clients enrolled in OHP medical plans, contact the plan.
Pharmacies that enroll as Oregon Medicaid providers with the Division of Medical Assistance Programs (DMAP) can bill DMAP for:
- Prescriptions dispensed to OHP members not enrolled in an OHP medical plan or coordinated care organization, and
- For all OHP members, certain mental health drugs not covered by OHP medical plans or coordinated care organizations.
The Oregon Medicaid Preferred Drug List, Oregon's Prioritized List of Health Services, and the federal Medicaid Drug Rebate Program determine DMAP prescription coverage.
All other prescriptions are billed to OHP medical plans or coordinated care organizations. These plans contract with DMAP to provide medical and prescription drug coverage to nearly 88 percent of OHP members statewide. Their coverage policies may differ from DMAP's, but they must follow Prioritized List coverage.
For more information, see DMAP's Frequently asked questions about DMAP prescription coverage.
Information for providers
DMAP's 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 DMAP instead of an OHP medical plan or coordinated care organization. Starting Jan. 1, 2011, DMAP's pharmacy program was the first in Oregon to adopt the OHA's new Average Actual Acquisition Cost (AAAC) methodology. More information about AAAC is available on the OHA Pharmacy website.
Receive DMAP Pharmaceutical Services program updates by e-mail
- Current rules on file with Oregon Secretary of State
- Supplemental information - Eligibility and coverage information; billing guidelines for professional and pharmaceutical services, including Medication Therapy Management (MTM); Point of Sale, ProDUR and prior authorization information; 340B program information; contact 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 managed care prescriptions.
- Billing information - Includes Point of Sale and payer sheet information, current rates, and coverage exceptions
- Clinical information - Information for prescribers, including prior authorization criteria, Drug Utilization Review information, and Preferred Drug List information
- Use Epocrates Rx, a free mobile drug reference that provides point-of-care access to the Oregon Medicaid Preferred Drug List and the formularies for most OHP medical plans.
- Learn how to become an OHP provider
Information for members
People with OHP Plus, OHP with Limited Drug, or OHP Standard benefits receive prescription drug coverage. Your doctor will know what prescriptions are covered, and your pharmacy will know whether you will need to pay a copayment.
- OHP home-delivery pharmacy - Enroll and pay no copayments for home-delivered drugs.
- Frequently asked questions about copayments
- If you need help - First call your OHP medical plan or coordinated care organization (number listed on your member ID or coverage letter). If you are not in a plan or still need help after calling the plan, then call OHP Client Services at 800-273-0557.
Mental health prescription drugs
Prescription drugs are an important part of keeping a patient healthy and preventing and treating illness. The Oregon Health Plan (OHP) uses evidence-based research to prepare a preferred drug list for members; managed care plans in Oregon use a similar list. As a member of the Oregon Health Plan, 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:
The Oregon Health Plan 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 Client Services: 1-800-273-0557.
- If an OHP member is enrolled in either a managed care organization (MCO) or a coordinated care organization (CCO), all physical health drugs are provided through the health plan. For questions about all non-mental health drugs, please contact your MCO or CCO directly.
- If an OHP member is enrolled in either an MCO or a CCO, all mental health drugs are provided through the state. For questions, please contact Client Services: 1-800-273-0557.
For more information, see this list of mental health drugs