Pharmaceutical services program
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Makena® (17-alpha-Hydroxyprogesterone Caproate) coverage effective October 1, 2013
- Makena® is a preferred agent, but requires prior authorization to ensure appropriate and safe use and should be billed through the pharmacy point of sale program.
- Compounded 17-alpha-Hydroxyprogesterone Caproate must comply with Oregon Board of Pharmacy OAR 855-045-0230 (1)(c).
- 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) - 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.
Oregon Medicaid Payer Sheet (pdf) - To bill DMAP using point of sale (POS), make sure your system meets the payer-specific requirements in this sheet.
Actual Average Acquisition Cost Reimbursement (link) - This page provides information on the new way the Oregon Health Authority reimburses pharmacies for Medicaid fee-for-service prescriptions, including:
- Weekly AAAC rates for brand and generic drugs
- Information about AAAC reimbursement rate review, forms and processes (link).
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."
See DMAP's Frequently-asked questions about drug pricing and reimbursement, and the following links:
- 7/11 carve-out list - 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 - 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).