The Oregon Health Plan (OHP) provides health coverage to many Oregon residents. Navigating the specifics of what treatments and medications are covered can be complex. This article provides a detailed overview of OHP's coverage policies, particularly focusing on weight loss medications, and how to access necessary healthcare services.
General OHP Coverage Policies
OHP doesn't cover all treatments for all health conditions. Some services have limitations, meaning they are only covered for specific conditions. Other services are simply not included in OHP's benefit package and are generally not covered. The Prioritized List of Health Services outlines which treatments and conditions OHP covers. Before providing a service, your healthcare provider should inform you whether it is limited or not covered.
Coverage Outside of Oregon
OHP may cover services received outside Oregon in specific situations:
- Medical Emergency: If you experience a medical emergency outside of Oregon.
- Service Not Readily Available in Oregon: If the required service is not easily accessible within Oregon, and your Coordinated Care Organization (CCO) or the Oregon Health Authority (OHA) has approved the service beforehand.
OHP does not cover any healthcare services received outside the United States, including in Canada and Mexico. For services outside Oregon, the provider must accept OHP. If they don't, you will be responsible for the cost.
In an emergency outside Oregon, inform the hospital that you are an OHP member and present your CCO ID and Oregon Health ID card. For non-emergency services, your CCO or OHA must grant prior approval.
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Prior Authorization
Prior authorization is a requirement where OHP or your CCO must approve a service before you can receive it. Services that often require prior authorization include:
- Dental services
- Durable medical equipment and supplies (wheelchairs, hospital beds, breast pumps)
- Home health care
- Hospital stays
- Imaging services (MRIs)
- Medical equipment and supplies (diabetic supplies, diapers, catheters)
- Out-of-state services
- Physical or occupational therapy
- Physical health drugs not listed on the Preferred Drug List or your CCO's formulary
- Speech and language services
- Specialty services
- Transplants
- Vision services for non-pregnant adults age 21 and over
- Services not covered according to the Prioritized List of Health Services.
This is not an exhaustive list, so always confirm with your provider and OHP whether a service requires prior authorization.
Coverage for Children and Youth (Under Age 21)
OHP or your CCO must cover all services needed for the health and development of children and youth under age 21. This includes services that may be limited or not covered for adults. Since January 1, 2023, OHP may cover additional services for children and youth that were previously not covered. If an OHP member under 21 needs a service, they should consult their healthcare provider about obtaining it.
Options When OHP Doesn't Cover a Service
If OHP does not cover a specific service, you have a few options:
- Explore alternative ways to get the service.
- Get a second opinion: Another provider might offer the same service at a lower cost.
Before receiving a service not covered by OHA or your CCO, you and your provider must sign a form that includes:
Read also: A guide to Mercy Care and weight loss medications.
- The name or a description of the service.
- The estimated cost of the service.
- A statement that OHP does not cover the service.
- Your signature agreeing to pay for the bill yourself.
OHP has specific Agreement to Pay forms for providers:
- The OHP 3166 for prescriptions.
- The OHP 4109 for planned community births.
- The OHP 3165 for other healthcare services.
You can also ask your provider for a reduced rate or a discount for paying privately. Be aware that other services related to the one you want (hospital, anesthesia, therapy, lab, or X-ray services) may also incur separate charges.
Medication Coverage
OHP covers many prescription drugs to help members maintain their health. You can find information about covered medicines, refills, limits, and more in the member handbook or on the OHP website. If you urgently need a drug that is not on the formulary, you, your provider, or your pharmacist can request an emergency 72-hour supply. To fill a prescription, you can visit any pharmacy within the OHP network.
Specialty Pharmacy Program
CareOregon has introduced a specialty pharmacy program for Medicaid members who require specific specialty medications. These medications may now be available through a specialized pharmacy that can better cater to your needs. If your pharmacy changes, the new pharmacy will contact you when you need a new prescription or refill. The medication itself (name, brand, and amount) will remain the same.
Navigating OHP Benefits
The summary of benefits and coverage offers an overview of the types of care OHP covers. Generally, OHP covers healthcare services within your benefit package that are:
Read also: Does Meritain Cover Weight Loss Drugs?
- Provided in the United States by providers who accept the Oregon Health ID card.
- Medically necessary (important for maintaining or improving your health).
For adults, OHP covers services based on your benefit package and the Prioritized List of Health Services. However, for children under 21, the Prioritized List does not determine benefit coverage. To determine if OHP covers a specific service or treatment for a particular health condition, consult your provider or CCO. You can also view the summary of OHP benefits and coverage online.
Practitioner-Managed Prescription Drug Plan (PMPDP) and Preferred Drug List (PDL)
Senate Bill 819 (2001) established the Practitioner-Managed Prescription Drug Plan (PMPDP). This requires OHP to maintain a list of the most cost-effective drugs to prescribe for fee-for-service members, known as the Preferred Drug List (PDL). Drugs not on the PDL are considered "non-preferred" and require prior authorization.
The Health Resources Commission (HRC) collaborates with Oregon Health & Science University's Center for Evidence-Based Policy to gather clinical data, information from pharmaceutical manufacturers, and public testimony. They evaluate this information using established evidence methods in a public forum. The HRC then submits recommendations to the division for pricing. The division makes cost-effective selections, creating the PDL.
The PDL aims to identify the most effective and safe drugs for most patients and serves as a tool to identify the most cost-effective drugs for open-card OHP patients. OHA recommends that practitioners consider drugs on the PDL first when starting a new medication.
GLP-1 Agonists and Weight Loss
Recently, there has been increased attention on GLP-1 agonists, such as Ozempic and Mounjaro, which are part of the standard of care for treating Type II Diabetes. The American Diabetes Association (ADA) recommends these medications, with or without metformin, as initial therapy for individuals with type II diabetes who have or are at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease.
However, many coverage requests for GLP-1 agonists appear to be for use outside of the FDA-approved indications. Trillium Community Health Plan, in collaboration with Centene Pharmacy Solutions, actively monitors and reviews prior authorization requests to ensure these medications are used only as approved by the FDA. Documentation may be required to substantiate attestations made in the prior authorization request process.
Trillium Community Health Plan
Trillium Community Health Plan updates its Preferred Drug List (PDL) monthly, and it is available online. The P&T Committee determines updates to coverage guidelines based on quarterly, comprehensive reviews. These criteria serve as a reference for providers when prescribing pharmaceutical products for Trillium members with pharmacy coverage. Prior authorization does not guarantee payment and is based on multiple factors in conjunction with the criteria posted in drug coverage guidelines.
For additional information regarding changes to the Trillium Preferred Drug List (PDL), you can contact Trillium by telephone at 1-877-600-5472.
Taking Action
To get started using your OHP benefits:
- Get to know your Coordinated Care Organization (CCO): Your CCO can assist you in obtaining the necessary care.
- Pick a provider.
- Make an appointment.
tags: #ohp #weight #loss #medication #coverage