121-0040-11012026.pdf: OAR 410-121-0040 amended for PA Criteria, implementing recommendations from DUR/P&T Action effective 11/01/2026.

The Oregon Health Authority (OHA), through the Health Systems Division's Medical Assistance Programs, filed Permanent Administrative Order DMAP 47-2026 on October 27, 2026, amending OAR 410-121-0040, effective November 1, 2026. The amendment also repeals the temporary version of 410-121-0040 issued under DMAP 44-2026. The rulemaking implements recommendations from the Drug Use Review/Pharmacy and Therapeutics (DUR/P&T) Committee to update Prior Authorization (PA) criteria for prescription drugs covered under the Oregon Health Plan (OHP) fee-for-service program. Under the amended rule, prescribing practitioners must obtain PA using procedures in OAR 410-121-0060 for drugs and drug categories identified in the rule. All covered drugs must be prescribed for conditions funded by OHP consistent with the Health Evidence Review Commission (HERC) Prioritized List of Health Services (OAR 410-141-3820 through 410-141-3825). Drugs prescribed for non-covered diagnoses are not covered unless a co-morbid covered condition exists, and use must align with corresponding treatment guidelines and the client's benefit package. The rule references the Oregon Medicaid Fee-for-Service Prior Authorization Approval Criteria guide, updated to the November 1, 2026 version, incorporated by reference and published at the OHA pharmacy policy page. PA is also required for brand-name drugs with two or more generic equivalents available, unless designated Narrow Therapeutic Index drugs by the DUR/P&T Committee. Immunosuppressant drugs used in organ transplantation are subject to a 180-day narrow therapeutic index evaluation window following U.S. patent expiration, with manufacturers required to notify OHA within 30 days of patent expiration. PA is required for non-preferred Preferred Drug List (PDL) products, with exceptions for mental health drugs as defined in OAR 410-121-0000, prescriptions written before January 1, 2010, refills for seizure, cancer, HIV, or AIDS treatment, and immunosuppressant refills. PA is not required when the ingredient cost plus dispensing fee is less than the PA processing fee, for covered OTC drugs prescribed for OHP-covered conditions, or for drug classes not evaluated under the Practitioner-Managed Prescription Drug Plan under ORS 414.334. New drugs added via the weekly First Databank upload are subject to immediate PA criteria application if their class has existing criteria, and all new drugs are subject to DUR/P&T Committee review.