MedicaidAdministrativeMedium impact
Provider Announcement
Oregon Health Plan·OR · Pharmacy·Provider
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Oregon Health Plan now requires pharmacies to use the new OHP 3166 form (Client Agreement to Pay for Pharmacy Services) when OHP members elect to pay out-of-pocket for prescriptions. This applies to non-covered drugs, prior authorization delays, or member preference scenarios. Pharmacies must obtain member and pharmacy representative signatures, maintain copies for 5 years, and retain records per OAR 410-120-1360(2).
Action Required
By January 1, 2020: Pharmacy billing team must obtain and implement the OHP 3166 form for all out-of-pocket payment scenarios. Specific actions: (1) Download OHP 3166 form from bit.ly/ohp-pharmacy under 'Forms' in 'Pharmacy Quick Links'; (2) Train pharmacy staff to use form when members request out-of-pocket payment for non-covered drugs, prior auth delays, or covered drugs with member preference; (3) Update intake/point-of-sale procedures to capture form completion; (4) Ensure member and pharmacy representative signatures on all forms; (5) Establish file management system to retain completed forms for minimum 5 years in pharmacy records; (6) Provide copies to members at time of signature. Consequences: Failure to use form may result in compliance violations under OAR 410-120-1280(3) and OAR 410-120-1360(2). For billing issues, contact Oregon Pharmacy Call Center at 888-202-2126 or appropriate CCO for coordinated care organization members.