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Pharmaceutical services program

Billing information

• General resources
• Point of sale resources
• MMIS information
• Pricing information
• Coverage information

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General resources

• National Provider Identifier look-up (link) - All pharmacy claims must include the prescriber's NPI in the Prescriber ID field. For more information, read this letter (pdf).
• OHP eligibility verification Web page (link)
• Oregon Pharmacy and Oral Nutritional Supplement PA Request (pdf) - Updated 7/23/09 - When requesting prior authorization for drugs or oral nutritional supplements dispensed to OHP clients on a fee-for-service basis, fax this form to the Oregon Pharmacy Call Center at 888-346-0178.
• Medicare Modernization Act (MMA) Web site (link) - For information about Medicare Part D.

Point of sale resources

• POS Payer Sheet (link) - Make sure your POS system is updated to meet the requirements in this payer sheet. Fields with claim submission changes are highlighted yellow.
• Compound billing instructions (pdf) - New! 10/27/09 - How to bill for compounded drugs in Point of Sale
• ProDUR Overview (pdf) - Updated 3/5/09 - How to override ProDUR alerts

Medicaid Management Information System (MMIS) information

• MMIS information page (link) - Everything you need to know about the new MMIS
• Provider Matters - Weekly updates from DMAP related to MMIS and claim processing

Pricing information

Oregon Maximum Allowable Cost (OMAC) List (pdf) - Effective 1/1/10. This list does not exclude other non-covered benefit package items, such as Long Term Care or Medicare D.

• An Excel file with the current list by NDC and by GCN is available at this link (zip file).
• To research or dispute a drug price on the OMAC list, fill out the OMAC Dispute Resolution and Research Request form (pdf) and fax to the Oregon Pharmacy Call Center at 888-346-0178.

Federal Upper Limits - For more information, see OAR 410-121-0300. For the latest information about Federal Upper Limit (FUL) pricing, go to the CMS Federal Upper Limits Web page.

• CMS has published an update to the FUL list that contains cumulative changes from 2002 through September 25, 2009. These updates can be found on their FUL Web page under "Changes made to Transmittal No. 37."

Coverage information

See DMAP's Frequently-asked questions about drug pricing and reimbursement, and the following links:

• Weekly 7/11 carve-out list (Excel) (PDF) - DMAP pays for the drugs on this list on a fee-for-service basis for all OHP clients, whether they are in managed care or not.
• Nursing Home list (pdf) - Updated 3/1/08. This list includes drugs not reimbursed by DMAP because they are included in the bundled rate for long-term care nursing facilities.
• DESI List (link) - Current Less-Than-Effective Drug list is on the CMS site. DMAP does not cover drugs that are on this list.
• Tamper-resistant prescription pad information (link) - DMAP will only reimburse fee-for-service outpatient prescriptions delivered in a tamper-resistant format (i.e., electronically or on tamper-resistant paper).

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Oregon Department of Human Services
Division of Medical Assistance Programs
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