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High-Cost Drug Carve-Out policy effective Jan. 1, 2026
Effective date
Jan 1, 2026
Identified
Jun 20, 2026
Summary
Oregon Health Authority will now reimburse certain high-cost drugs on a fee-for-service basis for all Oregon Health Plan members, including CCO enrollees. All drugs in this carve-out require prior authorization from OHA, and inpatient-administered drugs must be billed as outpatient hospital claims with acquisition cost invoices.
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What to do
Action · 3 steps
01Immediately for drugs administered on or after Jan 1, 2026: Submit prior authorization requests for all OHP members to Oregon Pharmacy Call Center at 888-202-2126 before administering high-cost drugs on HCDCO list.
02Billing team must bill inpatient-administered HCDCO drugs as outpatient hospital claims to OHA with acquisition cost invoice attached.
03Review HCDCO drug list at www.orpdl.org and updated Hospital Services Provider Guide for specific billing instructions.
If missed: Failure to obtain prior authorization will result in claim denials.
Original notice
High-Cost Drug Carve-Out policy effective Jan. 1, 2026
oregon.gov · Always check the source before changing claims.