Pharmacy benefit change: High cost drug carve out
What is changing?
Effective January 1, 2026 Oregon Health Authority (OHA) Fee For Service (FFS) will expand their drug carve out to include certain ultra-high cost (>$500,000 per year) drugs, in addition to previously covered mental health drugs. This includes pharmacy and medical claims. The list of drugs is posted on the OHA website here. This list includes drugs dispensed by a pharmacy and those that are physician administered.
This carve out means that CareOregon will no longer be responsible for adjudicating claims or prior authorization for these drugs themselves, but all related services (office visits, infusion codes, etc.) will still be CareOregon’s responsibility. Two separate claims will now need to be billed, one for the drug to OHA FFS and one to CareOregon for all other related services.
What do providers need to do?
Beginning December 22, 2025 all prior authorization requests for these drugs should use the OHA FFS prior authorization form and fax directly to OHA FFS at 888-346-0178.
OHA FFS will contact affected providers directly.
Who should providers reach out to for questions?
For questions, please contact the CareOregon pharmacy team at 503-416-4100 then follow prompts for option 3 (provider) and option 3 (pharmacy).
