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. (4) If the PA request has been denied, notification to client and prescriber will occur in accordance with OHP General Rules 410-120-1860. (5) 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.