Provider updates

Every year there are changes to certain benefits covered by CareOregon Advantage (COA). This year there are several member benefit changes and enhancements that go into effect January 1, 2027. These benefit changes do not require any action from providers but we want providers to be aware of these exciting changes and help educate members in using their benefits to the full extent.

What benefits are changing this year?

Below is a summary of the benefit changes. These enhancements help our members get more from their coverage than last year.

• Silver & Fit Fitness Benefit
  • Qualifying members will have access to gym locations with this benefit and are also eligible to receive one home fitness kit each year. There are five kit options for members to chose from.
• OTC (Over-The-Counter) Benefit
  • Qualifying members will have $70 per quarter (increased from the current $15.50 per month) to spend on over the counter items like pain relievers, cold medicine and first aid supplies.
• Special Supplemental Benefits for the Chronically Ill (SSBCI) Healthy Food Funds (CareCard)
  • Qualifying members will have $225 per quarter (increased from $50 per month) that can be used for food.
  • Members will have expanded eligibility to qualify for Healthy Foods. Providers will need to document a qualifying diagnoses in order for a member to meet the expanded eligibility. A list of qualifying diagnoses can be found in the Evidence of Coverage booklet. 
• Part D Formulary Changes
  • More drugs will be available to members with no cost sharing. There will be a $0 copay for preferred generic drugs (Tier 1) and select care drugs (Tier 6).
  • There will be copays for drugs on Tiers 2-5. Copays are based on the level of Extra Help (A Medicare program that helps pay for Part D drug costs based on limited income) members receive.
  • For Tier 2-5 medications used to treat chronic conditions, providers should consider prescribing a 100-day supply as members will pay the same amount for a 100-day supply as they would for a smaller day supply.
  • For more information about what medications are in which drug tiers, click here.
• Diabetic Series Completer Incentive
  • For members who have completed all three individual diabetic-related incentives available, there is a $50 incentive.
  • More information on this incentive and the other incentives available to members can be found here.

Additional administrative changes (no action needed from providers or members)

Part D Medication Therapy Management (MTM) vendor

• Arine will replace OptumRx as the MTM vendor.
• Members will receive written communication and verbal outreach from Arine.
• Providers should not experience any change in their processes

Cost sharing changes for members

• Removed the referral requirement from all services
• Members could potentially meet their deductible faster
• 20% co-insurance has been added to certain services

For the full details of CareOregon Advantage benefits for 2027, click here.

If you have any questions or require additional clarification, please contact CareOregon Provider Relations:

• CareOregon/Health Share: Metroprs@careoregon.org
• Jackson Care Connect: jacksonprs@careoregon.org
• Columbia Pacific CCO: colpacPRS@careoregon.org