OAR 410-121-0060
How to Get Prior Authorization for Drugs

(1)

A prescriber electing to order a drug requiring PA may have any licensed medical personnel in their office request the PA. The PA request may be transmitted to the Oregon Pharmacy Help Desk by any of the following methods:

(a)

Call the Oregon Pharmacy Help Desk

(b)

FAX the request form shown in the Pharmaceutical Services Supplemental Information on the Oregon Health Authority’s website to the Oregon Pharmacy Help Desk

(c)

Transmit the request electronically via the secure MMIS web portal.

(2)

The status of a PA request received from prescribers or their licensed medical personnel will be reported on the secure MMIS web portal, or by calling the Automated Voice Recognition (AVR) System, within 24 hours of receipt by the Oregon Pharmacy Help Desk

(3)

PA approval:

(a)

It is the pharmacy personnel’s responsibility to check whether the drugs are covered, whether the client is eligible, and to note restrictions such as date ranges and quantities before dispensing any medications that require PA.

(b)

The pharmacy personnel must also check whether the client’s prescribed medications are covered by a managed care plan because an enrollment may have taken place after PA was received. If the client is enrolled in a managed care plan and the pharmacy receiving the PA is not a participating pharmacy provider in the managed care plan’s network, the pharmacy must inform the client that it is not a participating provider in the managed care plan’s network and must also recommend that the client contact his or her managed care plan for a list of pharmacies participating in its network.

(c)

After a PA request is approved, the patient will be able to fill the prescription at any Medicaid pharmacy provider, if consistent with all other applicable administrative rules.

(3)

If the PA request has been denied, notification to client and prescriber will occur in accordance with OHP General Rules 410-120-1860 (Contested Case Hearing Procedures).

(4)

Emergency Need: The Pharmacist may request an emergent or urgent dispensing from the Pharmacy Benefits Manager (PBM) when the client is eligible for covered fee-for-service drug prescriptions.

(a)

Clients who do not have a PA pending may receive an emergency dispensing for a 96-hour supply.

(b)

Clients who do have a PA pending may receive an emergency dispensing up to a seven-day supply.

Source: Rule 410-121-0060 — How to Get Prior Authorization for Drugs, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-121-0060.

410–121–0000
Foreword and Definition of Terms 410–121–0021
Organizations Authorized to Provide Pharmaceutical Prescription Services 410–121–0030
Practitioner-Managed Prescription Drug Plan 410–121–0032
Supplemental Rebate Agreements 410–121–0033
Polypharmacy Profiling 410–121–0040
Prior Authorization Required for Drugs and Products 410–121–0060
How to Get Prior Authorization for Drugs 410–121–0061
Durable Medical Equipment, Medical Supplies, and Medical Surgical Services (Physician Administered Drugs) 410–121–0100
Drug Use Review 410–121–0111
Pharmacy and Therapeutics Committee 410–121–0135
Pharmacy Management Program 410–121–0143
Client Confidentiality 410–121–0145
Prescription Requirements 410–121–0146
Dispensing Limitations 410–121–0147
Exclusions and Limitations 410–121–0148
Dispensing in a Nursing Facility or Community Based Care Living Facility 410–121–0150
Billing Requirements 410–121–0155
Reimbursement 410–121–0157
Participation in the Medicaid Drug Rebate Program 410–121–0160
Dispensing Fees 410–121–0185
Pharmacy Based Immunization Delivery 410–121–0190
Medication Therapy Management Services and Clozapine Therapy Monitoring 410–121–0200
Billing Forms 410–121–0220
Instructions for Completion of the Prescription Drug Invoice 410–121–0280
Billing Quantities, Metric Quantities and Package Sizes 410–121–0300
CMS Federal Upper Limits for Drug Payments 410–121–0420
DESI Less-Than-Effective Drug List 410–121–0580
Oregon Medicaid and Pharmaceutical Manufacturers’ Dispute Resolution Procedures 410–121–0625
Items Covered in the All-Inclusive Rate for Nursing Facilities
Last Updated

Jun. 8, 2021

Rule 410-121-0060’s source at or​.us