Common Questions about the Health Share/CareOregon Prescription Drug Coverage

Common Questions about CareOregon's OHP Formulary

What is a formulary?

 

CareOregon has a list of covered drugs called a formulary. Pharmacists and doctors decide which drugs should be in the formulary. This formulary is effective on and after January 1 of the year, and is updated several times a year. To get up-to-date information about drugs covered by CareOregon, view our Drug List or call one of the following numbers between 8 a.m. and 5 p.m. Monday through Friday:

Customer Service

In the Portland metro-area: 503-416-4100

Toll-free: 1-800-224-4840

TTY/TDD:1-800-735-2900 or 7-1-1

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Which drugs are not covered by CareOregon?

 

To help members have the best possible health outcomes, CareOregon may add or remove drugs from the formulary or change coverage rules on drugs. If we remove a drug from the formulary or change the rules for a drug that you take, we will tell you beforehand.

These items are not covered:

  • Drugs not listed in the formulary
  • Drugs removed from the formulary in updates
  • Drugs used to treat conditions that are not covered by the Oregon Health Plan, such as fibromyalgia, allergic rhinitis, acne and chronic back pain
  • Drugs used for cosmetic purposes
  • Drugs used for non-medically accepted reasons
  • Investigational drugs and drugs used in an investigational manner

Drugs used to treat mental health conditions such as depression, anxiety and psychosis are covered by the Division of Medical Assistance Programs (DMAP). They are not listed on our formulary. Your pharmacist sends your prescription claim directly to DMAP. DMAP may require you to pay a copayment for these drugs.

Some drugs on the formulary have additional requirements or limits on coverage that may include:

  • The use of generic drugs when available
  • Prior authorization
  • Step therapy
  • Age restrictions
  • Quantity limits

CareOregon covers some over-the-counter (OTC) drugs, such as aspirin. They are listed on the formulary. You must get a prescription from your provider and give it to a pharmacist before CareOregon can pay for an OTC drug.

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What are coverage restrictions?

 

Some covered drugs have special rules for using them. Most drugs are limited to a 31-day supply per prescription. The earliest date that you can refill a prescription after getting a 31-day supply is 23 days after the last refill.

EXCEPTIONS: You may get up to a 90-day supply of the following drugs:

  • Generic oral contraceptives (birth control pills)
  • Pediatric multivitamins with fluoride and prenatal vitamins, folic acid, sodium fluoride
  • Digoxin, furosemide, hydrochlorothiazide, atenolol, metoprolol, captopril, enalapril, lisinopril
  • Levothyroxine
  • Albuterol HFA inhalers and nebulizer solutions

The earliest date that you can refill a prescription after you get a 90-day supply is 68 days after the last refill.

Note: CareOregon may approve an additional refill in the following situations:

  • Your prescription is lost, stolen or spilled
  • You need extra medication because you will be out of town
  • You need extra medication because your dosage was increased
  • You need a supply of a certain medication for work or school

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What questions should I ask about my new prescriptions?

 

For some drugs, your provider will need to check with CareOregon before we will cover the prescription.

  • Before you leave your provider’s office, ask if CareOregon covers the drug.
  • If CareOregon doesn’t cover it, ask if there is a covered drug that would work for you.
  • If your provider does not prescribe a different drug for you, ask your provider’s office staff to mail or fax a Prior Authorization or Formulary Exception Request Form to CareOregon.
  •  

    If you check with your provider before leaving the office, you will save time and be able to start your prescription as soon as possible. Be sure to follow your provider’s and pharmacist’s directions for taking your medication.

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How do I fill my prescriptions?

 

Fill your prescriptions at a Health Share/CareOregon network pharmacy. A list of Health Share/CareOregon pharmacies can be found using the Provider Search tool on our website.

Show your Health Share/CareOregon ID card every time you fill a prescription.

 

 

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What if I urgently need a non-formulary or restricted drug?

 

You, your provider or a pharmacist may ask for a five-day emergency supply of a non-formulary or restricted drug. This gives you, your provider or the pharmacist time to send a Prior Authorization or Formulary Exception Request Form to CareOregon. To ask for an emergency supply, call Health Share/CareOregon Customer Service at 503-416-4100 or toll free at 1-800-224-4840, Monday through Friday, 8 a.m. to 5 p.m. TTY/TDD users can call 1-800-735-2900 or 7-1-1.

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How do I get reimbursed if I paid for a prescription drug with my own money?

 

If you have paid for a prescription using your own money and you think you are entitled to be reimbursed by Health Share/CareOregon, you can fill out a Direct Member Reimbursement Form and return it to the address listed on the form.

If our decision for reimbursement is favorable, you can expect to receive payment after 30 days from the date we receive a completed request.

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What if I am doing well on a non-formulary or restricted drug for a chronic (constant) medical condition?

 

If you or your provider asks, CareOregon will provide a 60-day transition supply of a non-formulary or restricted drug for new members or members who move to a different care level. These members are usually stabilized (doing well) on a non-formulary or restricted formulary drug for chronic medical conditions. The transition supply allows time for you to try a different drug from the formulary if your provider thinks it is right for you. Or, your provider may send a Prior Authorization or Formulary Exception Request Form to CareOregon. 

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Can I fill my prescription if I travel outside of Oregon?

 

CareOregon’s pharmacy network includes most national pharmacy chains. If you need a prescription outside of Oregon, call Health Share/CareOregon Customer Service to find out if there is a contracted pharmacy near you.

If you pay for prescriptions, you may submit a Pharmacy Reimbursement Form.

Or, you may call Health Share/CareOregon Customer Service for help.
CareOregon makes reimbursement decisions based on your benefit coverage.

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How do I appeal if my prior authorization or formulary exception request was denied?

 

Call Health Share/CareOregon Customer Service as soon as possible.
Call 503-416-4100 or toll free at 1-800-224-4840. TTY/TDD users may call 1-800-735-2900 or 7-1-1. 
CareOregon must receive requests for reconsideration (appeals) no later than 45 days after the date on the original notice of action (denial) letter. We may ask for other information to support your appeal.

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Helpful Links

Drug Lookup This is a list of drugs covered by Health Share/CareOregon.

Optum Rx Mail Order Pharmacy Form for ordering prescriptions using a mail order pharmacy.

Pharmacy Reimbursement Form for Health Share/CareOregon OHP members.

If you need additional information, please call
Customer Service: 503-416-4100 or 1-800-224-4840
TTY/TDD Number: 1-800-735-2900 or 7-1-1