Oregon Health Plan (OHP) Prescription Coverage

For Coordinated Care Organization (CCO) Members

Oregon Health Authority (OHA) covers behavioral health (mental health and substance use disorder) prescriptions. The CCO covers most medical prescriptions.

Your doctor will know what prescriptions OHP covers.
The CCO's coverage policies may differ from OHA's. But they must follow Prioritized List coverage.
To learn more about CCO prescription coverage, see your CCO's member handbook and list of covered medications.

Moda Health will cover drugs prescribed by a dentist for Veteran Dental and COFA Dental members.

For Open Card (Fee-for-Service) Members

For members not enrolled in a CCO, OHA covers all prescriptions. These lists determine fee-for-service ("open card") coverage:

The Preferred Drug List
The Prioritized List of Health Services
The federal Medicaid Drug Rebate Program

The Preferred Drug List is the list of medications covered for open card members. You can find this list at www.orpdl.org. To look up your medication, you should know:

The medication's exact name
The dose you take and
How much your provider prescribes.

For Members with Medicare Coverage

OHP with Limited Drug covers only certain drugs that Medicare Part D does not cover.

If you have OHP with Limited Drug, your Medicare Part D drug plan will cover most of your prescriptions.
OHP will pay for the ones that OHP covers, but Part D doesn't cover. These include over-the-counter drugs and barbiturates.

If you choose not to enroll in a Part D drug plan, you will have to pay for drugs that Medicare Part D would cover if you had it. This means that unless you enroll in a Part D drug plan, you will pay out-of-pocket for most of your prescriptions.

Getting Prescriptions Filled

Go to a participating pharmacy. Make sure the pharmacy knows about all your health coverage:

OHP,
Your CCO, and
Any other coverage (such as private health insurance or Medicare).

Bring a picture ID with you, such as a driver's license or passport. Show all your health coverage ID cards. If you don't have your cards yet, tell the pharmacy you have OHP.

If you are a CCO member, go to a pharmacy in your CCO's network. Visit the CCO's website to find their participating pharmacies.

If you are not in a CCO, find a pharmacy that works with OHA. Use the online provider search. Search for the "Pharmacy" provider type.

Use the online provider search to find a pharmacy that works with OHA. Search for the "Pharmacy" provider type.

You can see if a mail order pharmacy is right for you.

Your CCO may have a mail-order prescription service. Call your CCO's customer service for information.

If you are not in a CCO, you can use the OHP Home Delivery Pharmacy Services program to get medications in the mail, at home or at your clinic. You can:

Fill prescriptions by mail or phone, or have your provider send the prescription for you
Get a three-month supply at one time if prescribed by your health care provider and
Get them delivered within eight to 10 days.

Learn more about OHP home-delivery pharmacy services.

If you have private health insurance and OHP, your insurance plan must work with pharmacies that can also bill OHP. This is to make sure OHP helps pay for your covered prescriptions.

If your pharmacy says they can bill your insurance, but not OHP:

Tell your insurance plan.
Ask the plan to tell you which pharmacies also bill OHP.
Use those pharmacies to fill your prescriptions.

If you are assigned to the Pharmacy Management Program, you must get all of your prescriptions filled at one walk-in pharmacy. Use the pharmacy noted on the “Managed Care/TPR enrollment" page of your coverage letter under “Pharmacy management."

Using a different pharmacy

You may fill your prescriptions at a different pharmacy if you have an urgent need and:

Your pharmacy is not open
You cannot get to your pharmacy, even using the OHP ride service or
Your pharmacy does not have the prescribed drug in stock.

Changing your assigned pharmacy

If you do not want to use the pharmacy shown on your coverage letter, you must change it within 30 days. Call OHP Client Services (800-273-0557, TTY 711) to do this. You can change pharmacies: