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Oregon Health Plan (Medicaid) prescription coverage

 

This page provides information about Oregon Health Plan (OHP) prescription coverage for pharmacies, prescribers and OHP clients. For information about prescription coverage for clients enrolled in OHP medical plans, contact the plan.

About OHP prescription drug coverage

Pharmacies that enroll as Oregon Medicaid providers with the Division of Medical Assistance Programs (DMAP) can bill DMAP for:

  • Prescriptions dispensed to OHP clients not enrolled in an OHP medical plan, and
  • For all OHP clients, certain mental health drugs not covered by OHP medical plans.

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. 15 medical plans contract with DMAP to provide medical and prescription drug coverage to nearly 83 percent of OHP clients 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. 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 email updates Receive DMAP Pharmaceutical Services program updates by e-mail 

  • Current rule book PDF
  • 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 PDF - 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
  • OHP pharmacy program announcements - Read recent updates here or eSubscribe to receive them via e-mail.
  • 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 clients

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 (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.

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