What to Do If You Are Asked to Pay for a Prescription

The Oregon Health Plan (OHP) Pays for Most Prescriptions at No Cost to You.

Note: If you signed an Agreement to Pay for the prescription, you do have to pay for it. Your providers must tell you whether services are covered by OHP before they give them to you..

Ask Your Pharmacy:

Your coordinated care organization (CCO) pays for most prescriptions.

Your CCO lists the drugs they cover on their website. This list is called a formulary.
Find your CCO's list of covered medications.

The Oregon Health Authority (OHA) pays for:

Some mental health prescriptions for all OHP members, and
Prescriptions for members not enrolled in a CCO.

Learn more about OHP prescription coverage.

If you have Medicare Part D, then OHP will only pay for prescriptions that Medicare does not cover.

If you have Medicare, you will need to pay for the prescription if:

You are not enrolled in Medicare Part D, and
The prescription is covered by Medicare Part D.

Make sure your pharmacy knows about all your health coverage, including OHP, your CCO, Medicare Part D, and private health insurance. If you have Medicare Part D or private health insurance, your pharmacy should bill those first.

This means your provider needs to ask OHA or your CCO to approve the prescription for payment.

Your CCO's list of covered drugs (or “formulary") notes which prescriptions require approval.
If you are not in a CCO or the prescription is for a mental health drug, the OHP Preferred Drug List notes which prescriptions require approval.

If you need the prescription right away and cannot wait for approval:

Your pharmacy can complete an Agreement to Pay for Pharmacy Services form with you.
If you complete and sign this form, this means you agree to pay for the prescription now. If it's approved later, the pharmacy will pay you back.

If You Think OHP Should Pay for the Prescription:

You can ask your CCO for an appeal. If your CCO thinks you should pay for the prescription, then you can ask OHA for a hearing. Learn more about appeals and hearings.