Or. Admin. Code § 836-053-1205

Current through Register Vol. 63, No. 12, December 1, 2024

Section 836-053-1205 - Uniform Prescription Drug Prior Authorization Request Form

(1) As used in this rule:

(a) "Material information" means information that is:

(A) Related to the patient's clinical condition sufficient to enable an individual with the appropriate training and experience to determine whether the prescription authorization request should be approved or disapproved; or

(B) Required by state or federal law for dispensing restricted prescription drugs.

(b) "Payer" means a person described in ORS 743.061(2) that requires prior authorization for prescription drug benefits.

(c) "Request form" means the Uniform Prescription Drug Prior Authorization Request Form set forth in Exhibit A of this rule.

(2) Any payer that requires prior authorization for a prescription drug benefit must accept a request for prior authorization for a prescription drug on the request form. A payer also may accept a prescription drug prior authorization request submitted on a form other than the request form.

(3)

(a) On or before July 1, 2015, a payer shall make the request form electronically available on their websites.

(b) On and after July 1, 2015, a payer shall:

(A) Accept the request form through any reasonable means of transmission, including but not limited to paper, electronic, or another mutually agreeable accessible method of transmission or using an internet or web-based system.

(B) Request from the prescribing provider only the minimum amount of material information necessary to approve or disapprove the prescription drug prior authorization request.

(C) Notify the prescribing provider within two business days after receipt of a completed request form that:

(i) The prescribing provider's request is approved;

(ii) The prescribing provider's request is disapproved as not medically necessary or not a covered benefit;

(iii) The prescribing provider's request is missing material information necessary to approve or disapprove the request; or

(iv) The patient is no longer eligible for coverage.

(4) A payer shall deliver any notice to a prescribing provider required under section (3) of this rule in the same manner the provider submitted the request form, or another mutually agreeable accessible method of notification.

(5) If a provider requests prescription drug prior authorization telephonically, through a web portal, or by any other manner of transmission, the payer may not require the prescribing provider to provide more information than is required by the request form.

(6) If a payer disapproves a prescribing provider's prior authorization request:

(a) Pursuant to paragraph (3)(b)(C))(ii) or (iii), the payer shall include in the notice of disapproval an accurate and clear written explanation of the specific reasons for disapproving the prior authorization request.

(b) Pursuant to paragraph (3)(b)(C)(iii), the payer also shall include in the notice of disapproval an accurate and clear written explanation that specifically identifies the missing material information that is necessary to approve or disapprove the prior authorization request.

(7) Every payer that conducts prescription drug prior authorizations shall have written policies and procedures in place to ensure that the payer complies with the requirements of ORS 743.065 and this rule.

(8) Requiring information in excess of the minimum material information specified by the request form shall constitute a failure to accept the request form, in violation of section (2) of this rule. A payer may not disapprove a request form on grounds of missing information under paragraph (3)(b)(C)(iii) of this rule if the form provides the minimum amount of material information in accordance with subsection (3)(b)(B) of this rule.

Or. Admin. Code § 836-053-1205

ID 4-2015, f. & cert. ef. 5/27/2015

Stat. Auth.: ORS 731.244, 743.065

Stats. Implemented: ORS 743.065