(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:
(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;
(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) July 1, 2024, 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:
(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;
(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;
(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:
(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;
(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;
(c) Criteria
for approval are:
(A) If criteria established
in section (4) or (5) of this rule applies, follow that criteria;
(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:
(a) The drug is a
mental
health drug as defined in OAR
410-121-0000;
(b) The original prescription is written
prior to 1/1/10;
(c) The
prescription is a refill for the treatment of seizures, cancer, HIV, or AIDS;
or
(d) The prescription is a refill
of an immunosuppressant.
(9) PA may not be required:
(a) When the prescription ingredient cost
plus the dispensing fee is less than the PA processing fees as determined by
the Authority;
(b) For
over-the-counter (OTC) covered drugs when prescribed for conditions covered
under OHP; or
(c) If a drug is in a
class not evaluated from the Practitioner-Managed Prescription Drug Plan under
ORS 414.334.
Notes
Or. Admin. Code
§
410-121-0040
AFS
56-1989, f. 9-28-89, cert. ef. 10-1-89; AFS 2-1990, f. & cert. ef. 1-16-90;
HR 29-1990, f. 8-31-90, cert. ef. 9-1-90, Renumbered from 461-016-0170; HR
10-1991, f. & cert. ef. 2-19-91; HR 14-1993, f. & cert. ef. 7-2-93; HR
25-1994, f. & cert. ef. 7-1-94; HR 6-1995, f. 3-31-95, cert. ef. 4-1-95; HR
18-1996(Temp), f. & cert. ef. 10-1-96; HR 8-1997, f. 3-13-97, cert. ef.
3-15-97; OMAP 1-1999, f. & cert. ef. 2-1-99; OMAP 29-2000, f. 9-29-00,
cert. ef. 10-1-00; OMAP 31-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 44-2002,
f. & cert. ef. 10-1-02; OMAP 66-2002, f. 10-31-02, cert. ef. 11-1-02; OMAP
29-2003, f. 3-31-03, cert. ef. 4-1-03; OMAP 40-2003, f. 5-27-03, cert. ef.
6-1-03; OMAP 43-2003(Temp), f. 6-10-03, cert. ef. 7-1-03 thru 12-15-03; OMAP
49-2003, f. 7-31-03, cert. ef. 8-1-03; OMAP 84-2003, f. 11-25-03, cert. ef.
12-1-03; OMAP 87-2003(Temp), f. & cert. ef. 12-15-03 thru 5-15-04; OMAP
9-2004, f. 2-27-04, cert. ef. 3-1-04; OMAP 71-2004, f. 9-15-04, cert. ef.
10-1-04; OMAP 74-2004, f. 9-23-04, cert. ef. 10-1-04; OMAP 89-2004, f.
11-24-04, cert. ef. 12-1-04; OMAP 4-2006(Temp), f. & cert. ef. 3-15-06 thru
9-7-06; OMAP 32-2006, f. 8-31-06, cert. ef. 9-1-06; OMAP 41-2006, f. 12-15-06,
cert. ef. 1-1-07; DMAP 4-2007, f. 6-14-07, cert. ef. 7-1-07; DMAP 26-2007, f.
12-11-07, cert. ef. 1-1-08; DMAP 9-2008, f. 3-31-08, cert. ef. 4-1-08; DMAP
16-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 34-2008, f. 11-26-08, cert. ef.
12-1-08; DMAP 14-2009, f. 6-12-09, cert. ef. 7-1-09; DMAP 39-2009, f. 12-15-09,
cert. ef. 1-1-10; DMAP 17-2010, f. 6-15-10, cert. ef. 7-1-10; DMAP 40-2010, f.
12-28-10, cert. ef. 1-1-11; DMAP 27-2011(Temp), f. & cert. ef. 9-30-11 thru
3-15-12; DMAP 44-2011, f. 12-21-11, cert. ef. 1-1-12; DMAP 12-2012(Temp), f.
& cert. ef. 3-16-12 thru 9-11-12; DMAP 18-2012, f. 3-30-12, cert. ef.
4-9-12; DMAP 23-2012(Temp), f. & cert. ef. 4-20-12 thru 10-15-12; DMAP
27-2012(Temp), f. & cert. ef. 5-14-12 thru 10-15-12; DMAP 29-2012, f. &
cert. ef. 6-21-12; DMAP 33-2012(Temp), f. 7-18-12, cert. ef. 7-23-12 thru
1-18-13; DMAP 40-2012(Temp), f. & cert. ef. 8-20-12 thru 1-18-13; DMAP
44-2012(Temp), f. & cert. ef. 9-26-12 thru 1-18-13; DMAP 61-2012, f.
12-27-12, cert. ef. 1-1-13; DMAP 6-2013(Temp), f. & cert. ef. 2-21-13 thru
8-19-13; DMAP 23-2013(Temp), f. 4-30-13, cert. ef. 5-1-13 thru 8-19-13; DMAP
43-2013, f. & cert. ef. 8-16-13; DMAP 76-2013(Temp), f. 12-31-13, cert. ef.
1-1-14 thru 6-30-14; DMAP 14-2014(Temp), f. & cert. ef. 3-21-14 thru
9-17-14; DMAP 27-2014(Temp), f. & cert. ef. 5-2-14 thru 6-30-14; DMAP
38-2014, f. & cert. ef. 6-30-14; DMAP 46-2014(Temp), f. & cert. ef.
7-15-14 thru 1-11-15; DMAP 49-2014(Temp), f. & cert. ef. 8-13-14 thru
1-11-15; DMAP 62-2014(Temp), f. 10-13-14, cert. ef. 10-14-14 thru 1-11-15; DMAP
75-2014, f. & cert. ef. 12-12-14; DMAP 76-2014(Temp), f. & cert. ef.
12-12-14 thru 6-7-15; DMAP 89-2014(Temp), f. 12-31-14, cert. ef. 1-1-15 thru
6-26-15; DMAP 4-2015(Temp), f. & cert. ef. 2-3-15 thru 6-26-15; DMAP
25-2015(Temp), f. 4-17-15, cert. ef. 4-18-15 thru 6-26-15; DMAP 34-2015, f.
6-25-15, cert. ef 6-26-15; DMAP 36-2015(Temp), f. 6-26-15, cert. ef. 7-1-15
thru 12-27-15; DMAP 41-2015(Temp), f. & cert. ef. 8-7-15 thru 2-2-16; DMAP
44-2015(Temp), f. 8-21-15, cert. ef. 8-25-15 thru 12-27-15; DMAP 58-2015(Temp),
f. & cert. ef. 10-9-15 thru 12-27-15; DMAP 80-2015, f. 12-23-15, cert. ef.
12-27-15; DMAP 83-2015(Temp), f. 12-23-15, cert. ef. 1-1-16 thru 6-28-16; DMAP
6-2016(Temp), f. 2-11-16, cert. ef. 2-12-16 thru 6-28-16; DMAP 19-2016(Temp),
f. 4-28-16, cert. ef. 5-1-16 thru 6-28-16; DMAP 26-2016, f. 6-24-16, cert. ef.
6-28-16; DMAP 35-2016(Temp), f. 6-30-16, cert. ef. 7-1-16 thru 12-27-16; DMAP
54-2016(Temp), f. & cert. ef. 8-26-16 thru 12-27-16; DMAP 62-2016(Temp), f.
& cert. ef. 10-13-16 thru 12-27-16; DMAP 68-2016, f. & cert. ef.
12-1-16; DMAP 79-2016(Temp), f. 12-29-16, cert. ef. 1-1-17 thru 6-29-17; DMAP
5-2017(Temp), f. & cert. ef. 2-21-17 thru 6-29-17; DMAP 10-2017(Temp), f.
3-31-17, cert. ef. 4-1-17 thru 6-29-17; DMAP 11-2017(Temp), f. 3-31-17, cert.
ef. 6-1-17 thru 6-29-17; DMAP 22-2017, f. & cert. ef. 6-29-17; DMAP
28-2017(Temp), f. 6-30-17, cert. ef. 7-1-17 thru 12-27-17; DMAP 32-2017(Temp),
f. & cert. ef. 8-24-17 thru 12-27-17; DMAP 45-2017, temporary amend filed
11/02/2017, effective 11/02/2017 through 12/27/2017; DMAP 52-2017, amend filed
12/26/2017, effective 12/27/2017; DMAP 61-2017, temporary amend filed
12/27/2017, effective 01/01/2018 through 06/29/2018; DMAP 8-2018, temporary
amend filed 02/08/2018, effective 02/08/2018 through 06/29/2018; DMAP 26-2018,
temporary amend filed 05/02/2018, effective 05/02/2018 through 06/29/2018; DMAP
75-2018, amend filed 06/22/2018, effective 06/29/2018; DMAP 76-2018, temporary
amend filed 06/27/2018, effective 07/01/2018 through 12/27/2018; DMAP 85-2018,
temporary amend filed 08/15/2018, effective 08/15/2018 through 12/27/2018; DMAP
92-2018, temporary amend filed 09/18/2018, effective 10/01/2018 through
12/27/2018; DMAP 95-2018, temporary amend filed 10/25/2018, effective
11/01/2018 through 12/27/2018; DMAP 112-2018, amend filed 12/21/2018, effective
12/22/2018;
DMAP
113-2018, temporary amend filed 12/21/2018, effective
1/1/2019 through 06/29/2019;
DMAP
3-2019, temporary amend filed 03/07/2019, effective
3/7/2019 through 06/29/2019;
DMAP
9-2019, temporary amend filed 04/09/2019, effective
5/1/2019 through 06/29/2019;
DMAP
11-2019, amend filed 05/21/2019, effective
6/13/2019;
DMAP
19-2019, temporary amend filed 06/19/2019, effective
7/1/2019 through 12/27/2019;
DMAP
31-2019, temporary amend filed 08/13/2019, effective
8/19/2019 through 12/27/2019; DMAP 40-2019,
temporary amend filed 10/01/2019, effective 10/01/2019 through 12/27/2019; DMAP
42-2019, temporary amend filed 10/23/2019, effective 11/01/2019 through
12/27/2019; DMAP 54-2019, amend filed 12/12/2019, effective 12/27/2019; DMAP
67-2019, temporary amend filed 12/27/2019, effective 01/01/2020 through
06/28/2020; DMAP 6-2020, temporary amend filed 02/25/2020, effective 03/01/2020
through 06/28/2020; DMAP 29-2020, amend filed 06/24/2020, effective 06/28/2020;
DMAP
32-2020, temporary amend filed 06/26/2020,
effective
7/1/2020 through 12/27/2020;
DMAP
41-2020, temporary amend filed 08/25/2020, effective
9/1/2020 through 12/27/2020;
DMAP
57-2020, temporary amend filed 10/26/2020, effective
11/1/2020 through 12/27/2020; DMAP 65-2020, amend
filed 12/21/2020, effective 12/27/2020;
DMAP
69-2020, temporary amend filed 12/28/2020, effective
1/1/2021 through 6/29/2021;
DMAP
8-2021, temporary amend filed 02/26/2021, effective
3/1/2021 through 6/29/2021;
DMAP
16-2021, temporary amend filed 04/23/2021, effective
5/1/2021 through 6/29/2021; DMAP 25-2021, amend
filed 06/24/2021, effective 06/29/2021;
DMAP
27-2021, temporary amend filed 06/28/2021, effective
7/1/2021 through 12/27/2021;
DMAP
53-2021, temporary amend filed 12/28/2021, effective
12/28/2021;
DMAP
54-2021, temporary amend filed 12/29/2021, effective
1/1/2022 through 6/25/2022; DMAP 45-2022, temporary
amend filed 04/01/2022, effective 04/01/2022 through 06/25/2022;
DMAP
50-2022, temporary amend filed 04/27/2022, effective
4/27/2022 through 6/25/2022;
DMAP
61-2022, amend filed 06/26/2022, effective
6/27/2022;
DMAP
64-2022, temporary amend filed 06/29/2022, effective
7/1/2022 through 12/27/2022;
DMAP
75-2022, temporary amend filed 09/29/2022, effective
10/1/2022 through 12/27/2022;
DMAP
87-2022, amend filed 12/13/2022, effective
12/20/2022;
DMAP
95-2022, temporary amend filed 12/27/2022, effective
1/1/2023 through 6/24/2023;
DMAP
10-2023, amend filed 03/28/2023, effective
4/1/2023;
DMAP
39-2023, amend filed 04/28/2023, effective
5/1/2023;
DMAP
54-2023, amend filed 06/30/2023, effective
7/1/2023;
DMAP
74-2023, amend filed 08/27/2023, effective
9/1/2023;
DMAP
83-2023, amend filed 10/31/2023, effective
11/1/2023;
DMAP
96-2023, amend filed 12/22/2023, effective
1/1/2024; DMAP 84-2024, amend filed
04/04/2024, effective 04/04/2024;
DMAP
87-2024, amend filed 05/01/2024, effective
5/1/2024;
DMAP
109-2024, amend filed 07/01/2024, effective
7/1/2024;
DMAP
119-2024, temporary amend filed 08/28/2024, effective
9/1/2024 through
2/27/2025
Statutory/Other Authority: ORS
413.032,
413.042,
414.065,
414.330 -
414.414,
414.312,
414.316 & ORS
414.325
Statutes/Other Implemented: 414.065, 414.334, 414.361,
414.371, 414.353, 414.354, ORS
414.325 & ORS
414.369
