Oregon Medicaid Prior Authorization Form

Updated January 23, 2022

An Oregon Medicaid prior authorization form requests Medicaid coverage for a non-preferred drug in the State of Oregon. As well as providing patient details and information regarding the requested drug, the prescribing physician must provide a medical justification for this request and attach any relevant notes and/or lab results. A drug is non-preferred when it is not listed on the State-approved Preferred Drug List or is listed as requiring Prior Authorization (PA) approval.

Fax – 1 (888) 346-0178

Phone – 1 (888) 202-2126

Updated Version of the Preferred Drug List

How to Write

Step 1 – Download the form and open it using Microsoft Word or Adobe Acrobat.

Step 2 – Begin filling out the form by providing the following “Requesting Provider” information into the appropriate fields:

  • Provider name
  • Provider NPI number
  • Provider contact name
  • Provider contact phone number
  • Provider contact fax number
  • Processing time frame (Routine/Urgent/Immediate)
  • Justification for urgent/immediate processing (if applicable)

Step 3 – Next, tick the appropriate checkbox to indicate if this is a pharmacy request, oral nutritional supplements request, physician-administered drug request, or “Other” (if you ticked “Other” type the category in the provided field).

Step 4 – In the “Client Information” section, you must enter the client’s ID number, date of birth, and full name.

Step 5 – Beneath “Service Information,” provide the following information:

  • Estimated length of treatment
  • Frequency
  • Primary diagnosis
  • Primary diagnosis code
  • Other pertinent diagnoses (if applicable)

Step 6 – In the “Drug/Product Information” section, you will need to provide the drug name, strength, quantity, and NDC number.  Next, if known, enter the participating pharmacy name, phone number, and the date.

Step 7 – Write in the date of the request, the expected start and end date for this treatment.

Step 8 – If you are requesting coverage for oral nutritional supplements, you will need to complete sections “VI” and “VIII.” In section “VI,” you will need to list and describe all the applicable prescribed supplements and their cost. In section “VIII,” use the checkboxes to answer all the questions regarding this prescribed treatment and provide the required details regarding the Registered Dietician’s assessment of the patient.

Step 9 –  Provide your “Written justification and attachments” into the indicated blank field at the bottom of the second page. Reference any medical forms that you will be attaching to support your justification.

Step 10 – Sign and date the form before sending it to the appropriate directory.