Federal Medicaid program integrity regulations — 42 CFR §455.410(b), 42 CFR §455.440 and the Medicaid Provider Enrollment Compendium, Section 1.3 — require all pharmacies that fill prescriptions for Medicaid members to be enrolled as a Medicaid pharmacy in the member’s state. If they are not enrolled, Medicaid cannot cover the prescription. This is true even if the pharmacy is enrolled as a Medicaid provider in a different state. Hospital, retail and other pharmacies are all included in this rule.
In compliance with these regulations, CareOregon will stop covering prescriptions filled at non-Medicaid pharmacies as of February 15, 2021.
If you want to see if you are already enrolled with the Oregon Health Authority, you can check by accessing the tool found here. If you’re not yet enrolled, please complete the OHP 3113 form no later than February 15, 2021. You can find the form in the “Policies and forms” section of this page. Once you’ve filled out the form, please fax it back to 503-416-1354.
If you decide not to enroll
It is your responsibility to:
- Notify any CareOregon, Columbia Pacific CCO or Jackson Care Connect patient if you are not an Oregon Medicaid pharmacy before providing services.
- If they still want to receive services from you, complete a form holding the patient responsible for paying for all services, including prescription drugs. This form can be found here.
After February 15, CareOregon will consider exceptions to rejected prescriptions on a case-by-case basis.
More information and questions
To learn more about this requirement, see Oregon Administrative Rules 410-120-1280 (Billing) and 410-141-3395 (Member Protection Provisions) in Oregon’s Medical Assistance Program rules.
If you have any questions, please call the CareOregon Pharmacy Department at 800-224-4840.