MedicaidPrior AuthHigh impact
High-Cost Drug Carve-Out policy effective Jan. 1, 2026
Oregon Health Plan·OR·Provider
Effective date
Jan 1, 2026
We identified it
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.
Action Required
Immediately 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. Billing team must bill inpatient-administered HCDCO drugs as outpatient hospital claims to OHA with acquisition cost invoice attached. Review HCDCO drug list at www.orpdl.org and updated Hospital Services Provider Guide for specific billing instructions. Failure to obtain prior authorization will result in claim denials.