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Oregon Medicaid Prior Authorization Form

Oregon Medicaid Prior Authorization Form

Updated July 27, 2023

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