Oregon's Division of Financial Regulation adopted form 440-4992 under OAR 836-053-1205 as the uniform request payers must accept for prescription drug prior authorization. A prescriber meets it when an Oregon health plan requires approval before covering a medication. The plan named at the top reviews the medical rationale, prior drugs tried and supporting clinical records, and issues or extends an authorization.
The prescribing provider completes the whole form: urgency, request type, patient and secondary insurance details, prescriber or servicing provider information, the patient's PCP, medication details, previous drugs and diagnosis codes. The plan's name, address and contact numbers sit in the header block.
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Uniform Prior Authorization Prescription Request Form
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Yes. The form is the exhibit to OAR 836-053-1205, the Division of Financial Regulation rule that sets the uniform prescription drug prior authorization request payers must accept in Oregon. The plan's own name, address and contact numbers go in the header so the form reaches the right reviewer.
It asks whether the request is new therapy or a renewal, with the date therapy started for renewals, the route and where the drug is given, and a list of previous drugs tried with dosages. The rationale section then explains why a formulary alternative is not acceptable.