Or. Admin. R. 410-121-0040 – Prior Authorization Required for Drugs and Products

(1) Prescribing practitioners shall obtain prior authorization (PA) for the drugs and categories of drugs requiring PA in this rule, using the procedures set forth in OAR 410-121-0060.
(2) Except as provided in section (3) of this rule, all drugs and categories of drugs including, but not limited to, those drugs and categories of drugs that require PA shall meet the following requirements for coverage:
1. (a) Each drug shall be prescribed for conditions funded by the Oregon Health Plan (OHP) in a manner consistent with the Health Evidence Review Commission (HERC) Prioritized List of Health Services (OAR 410-141-3820 through 410-141-3825). If the medication is for a non-covered diagnosis, the medication may not be covered unless there is a co-morbid condition for which coverage would be allowed. The use of the medication shall meet corresponding treatment guidelines and be included within the client’s benefit package of covered services and not otherwise excluded or limited;
2. (b) Each drug shall also meet other criteria applicable to the drug or category of drug in these pharmacy provider rules, including PA requirements imposed in this rule.
(3) The Division shall grant exceptions to section (2) of this rule when coverage is required through Early and Periodic Screening, Diagnostic and Treatment (EPSDT) as set forth in chapter 410 division 151.
(4) The Authority may require PA for individual drugs and categories of drugs to ensure that the drugs prescribed are indicated for conditions funded by OHP and consistent with the Prioritized List of Health Services and its corresponding treatment guidelines (see OAR 410-141-3820). The drugs and categories of drugs that the Authority requires PA for this purpose are found in the Oregon Medicaid Fee-for-Service Prior Authorization Approval Criteria (PA Criteria guide) June 1, 2026 adopted and incorporated by reference and found at https://www.oregon.gov/oha/HSD/OHP/Pages/Policy-Pharmacy.aspx
(5) The Authority may require PA for individual drugs and categories of drugs to ensure medically appropriate use or to address potential client safety risk associated with the particular drug or category of drug, as recommended by the Pharmacy & Therapeutics Committee (P&T) and adopted by the Authority in this rule. The drugs and categories of drugs for which the Authority requires PA for this purpose are found in the Pharmacy PA Criteria Guide.
(6) New drugs shall be evaluated when added to the weekly upload of the First Databank drug file:
1. (a) If the new drug is in a class where current PA criteria apply, all associated PA criteria shall be required at the time of the drug file load;
2. (b) If the new drug is indicated for a condition below the funding line on the Prioritized List of Health Services, PA shall be required to ensure that the drug is prescribed for a condition funded by OHP;
3. (c) PA criteria for all new drugs shall be reviewed by the DUR/P&T Committee.
(7) PA shall be obtained for brand name drugs that have two or more generically equivalent products available and that are not determined Narrow Therapeutic Index drugs by the DUR/P&T Committee:
1. (a) Immunosuppressant drugs used in connection with an organ transplant shall be evaluated for narrow therapeutic index within 180 days after United States patent expiration;
2. (b) Manufacturers of immunosuppressant drugs used in connection with an organ transplant shall notify the Authority of patent expiration within 30 days of patent expiration for section (5)(a) of this rule to apply;
3. (c) Criteria for approval are:
  1. (A) If criteria established in section (4) or (5) of this rule applies, follow that criteria;
  2. (B) If section (7)(a) of this rule does not apply, the prescribing practitioner shall document that the use of the generically equivalent drug is medically contraindicated and provide evidence that either the drug has been used and has failed or that its use is contraindicated based on evidence-based peer reviewed literature that is appropriate to the client’s medical condition.
(8) PA shall be obtained for non-preferred Preferred Drug List (PDL) products in a class evaluated for the PDL except in the following cases:
1. (a) The drug is a mental health drug as defined in OAR 410-121-0000;
2. (b) The original prescription is written prior to 1/1/10;
3. (c) The prescription is a refill for the treatment of seizures, cancer, HIV, or AIDS; or
4. (d) The prescription is a refill of an immunosuppressant.
(9) PA may not be required:
1. (a) When the prescription ingredient cost plus the dispensing fee is less than the PA processing fees as determined by the Authority;
2. (b) For over-the-counter (OTC) covered drugs when prescribed for conditions covered under OHP; or
3. (c) If a drug is in a class not evaluated from the Practitioner-Managed Prescription Drug Plan under ORS 414.334.

Statutory/Other Authority

ORS 413.032, 413.042, 414.065, 414.330 - 414.414, 414.312, 414.316 & 414.325

Statutes/Other Implemented

414.065, 414.334, 414.361, 414.371, 414.353, 414.354, 414.325 & 414.369

History