Oregon Medicaid (Oregon Health Plan) GLP-1 Coverage 2026: Pattern #29 — HERC Prioritized List Guideline Note 5 Evidence-Based-Coverage Exclusion (Structurally Unique in 50-State Series) + Wegovy CV + Wegovy/Liraglutide MASH (August 2024 Early Adoption Before FDA Approval) + Zepbound OSA + Foundayo on PDL No PA Criteria + No Third-Party PBM + DURM/OSU Academic-Pharmacy Model + 15 CCOs

Oregon Medicaid — branded the Oregon Health Plan (OHP), administered by the Oregon Health Authority (OHA) through its Health Systems Division, with care delivered through 15 Coordinated Care Organizations (CCOs) under CCO 2.0 contracts and a fee-for-service (FFS) pharmacy benefit managed directly by OHA Pharmacy Services with clinical and DUR functions contracted to the Drug Use Research and Management (DURM) group at Oregon State University College of Pharmacy — does not cover GLP-1 receptor agonists or any other anti-obesity medications for chronic weight management in adults age 21 or older. Oregon is Pattern #29 in the 50-state Medicaid GLP-1 series: the HERC Prioritized List Guideline Note 5 evidence-based-coverage exclusion state — the only state in the entire 29-state series where the operative AOM exclusion mechanism sits in an evidence-based coverage list rather than a pharmacy-benefit regulation.

TL;DR: Oregon Health Plan GLP-1 Coverage at a Glance

Oregon Health Plan DOES NOT cover GLP-1 receptor agonists or any other anti-obesity medications for the chronic weight-management FDA indication in adults age 21 or older. The exclusion is anchored at four independent authority levels:

1. HERC Prioritized List Guideline Note 5 at Line 317 — verbatim: “Pharmacological treatments and devices (e.g., gastric balloons, duodenal jejunal bypass liners, and vagus nerve blocking devices) for obesity are not intended to be included as services on this line or any other line on the Prioritized List.”
2. OAR 410-121-0040 — conditions all OHP drug coverage on consistency with the HERC Prioritized List.
3. Weight Management Drugs PA Criteria document at OregonPDL.org — verbatim Step 12: “drugs are not covered by OHP for adults when indicated for weight loss.”
4. 42 U.S.C. § 1396r-8(d)(2)(A) — the federal optional exclusion for “Agents when used for anorexia, weight loss, or weight gain.”

Oregon Health Plan DOES cover GLP-1 receptor agonists, with prior authorization, for three FDA-approved non-weight-loss indications under the Weight Management Drugs PDL class:

• Wegovy (semaglutide) — for established cardiovascular disease (CV risk reduction) in adults with confirmed prior MI, stroke, or symptomatic peripheral arterial disease, plus BMI ≥ 25 kg/m², negative diabetes screen within 12 months.
• Wegovy (semaglutide) injection — for noncirrhotic MASH stage F2–F3 fibrosis in adults ≥18. PA criteria formalized February 5, 2026; implementation March 1, 2026.
• Liraglutide — for noncirrhotic MASH stage F2–F3 fibrosis in adults ≥18. Liraglutide MASH coverage was created in August 2024 based on compendial designations and phase 2 evidence — one full year before the FDA approved Wegovy for MASH (August 2025). Oregon was ahead of the FDA on this indication.
• Zepbound (tirzepatide) — for moderate-to-severe obstructive sleep apnea (OSA) in adults with BMI ≥ 30, polysomnogram-confirmed AHI ≥ 15, failed or contraindicated PAP therapy.

Three additional coverage notes: (1) Foundayo (orforglipron), the recently FDA-approved oral GLP-1 agonist from Lilly, is listed on the Oregon Weight Management Drugs PDL class with Pharmacy PA — but no defined PA criteria have been adopted as of 2026-05-10. This makes Oregon the first state in the 29-state series to list Foundayo on its AOM PDL class, an early-adoption signal. (2) GLP-1 receptor agonists are covered for type 2 diabetes mellitus via a separate GLP-1 RA/GIP RA PA pathway (12-month authorization; preferred T2DM agents include dulaglutide, exenatide, liraglutide). (3) Members under age 21 (EPSDT) and members under 26 born in or after 2004 (YSHCN) may access weight management medications through a pediatric carve-in PA pathway.

Architecture: Oregon has no third-party PBM — OHA Pharmacy Services administers the FFS pharmacy benefit directly, and DURM at Oregon State University College of Pharmacy provides clinical, DUR, and P&T Committee functions. Oregon Pharmacy Call Center: 888-202-2126. Email: dmap.rxquestions@oha.oregon.gov.

The HERC Prioritized List of Health Services — Oregon’s Unique Coverage Mechanism

Oregon’s Medicaid coverage policy is built on a foundation that exists nowhere else in the United States: the Health Evidence Review Commission (HERC) Prioritized List of Health Services, created by the 1989 Oregon Basic Health Services Act. The Prioritized List ranks paired condition-treatment services by clinical effectiveness and cost-effectiveness. The Oregon Legislature funds a specific “funding line” each biennium; services below the line are not covered. Services above the line are covered — but only for the treatment types authorized by the relevant Guideline Notes.

The current Prioritized List — effective January 1, 2026, with errata as of January 29, 2026 — funds Lines 1–470. The funding-line statement on the HERC page reads verbatim:

“Oregon’s legislature approved funding for lines 1–470 of the prioritized list. The funding line will remain at this level through December 31, 2026.”

Line 317 — “OBESITY IN ADULTS AND CHILDREN; OVERWEIGHT STATUS IN ADULTS WITH CARDIOVASCULAR RISK FACTORS” — is above the funding line. Line 317 is funded. The coverage limitation on Line 317 is not a funding issue. It is a textual restriction imposed by Guideline Note 5. The verbatim Line 317 entry reads:

“317 — OBESITY IN ADULTS AND CHILDREN; OVERWEIGHT STATUS IN ADULTS WITH CARDIOVASCULAR RISK FACTORS (See Guideline Notes 5 and 8)

BEHAVIORAL INTERVENTIONS INCLUDING INTENSIVE NUTRITIONAL AND PHYSICAL ACTIVITY COUNSELING; BARIATRIC SURGERY

ICD-10 codes: E66.01–E66.3, E66.811–E66.9, E88.82, Z46.51, Z68.25–Z68.45, Z68.53–Z68.56, Z71.3, Z71.82”

The funded treatments at Line 317 are behavioral interventions and bariatric surgery — not pharmacotherapy. The reason is Guideline Note 5:

“GUIDELINE NOTE 5, OBESITY AND OVERWEIGHT

Line 317

Medical treatment of overweight (with known cardiovascular risk factors) and obesity in adults is limited to intensive counseling on nutrition and physical activity, provided by health care professionals. Intensive counseling is defined as face-to-face contact more than monthly. A multidisciplinary team is preferred, but a single clinician could also deliver intensive counseling in primary care or other settings.

Intensive counseling visits are included on this line for 6 months. Intensive counseling visits may continue for an additional 6 months (up to 12 months) as long as there is evidence of continued weight loss or improvement in cardiovascular risk factors based on the intervention.

Maintenance visits at the conclusion of the intensive treatment are included on this line no more than monthly after this intensive counseling period. The characteristics of effective behavioral interventions include: high intensity programs; multicomponent (including at a minimum diet and exercise), group-based commercial programs; Mediterranean diet; and the following sub-elements — calorie counting, contact with a dietician, and comparison to peers.

Known cardiovascular risk factors in overweight persons for which this therapy is effective include: hypertension, dyslipidemia, prediabetes, or the metabolic syndrome.

Treatment of prediabetes with the Diabetes Prevention Program (DPP) is addressed on Line 3 in Guideline Note 179. The DPP program can be used as an alternative to the intensive counseling as above, even in the absence of prediabetes as required by Guideline Note 179.

Medical treatment of obesity in children up to age 21 is limited to comprehensive, intensive behavioral interventions. For treatment of children up to 12 years old, interventions may be targeted only to parents, or to both parents and children.

Pharmacological treatments and devices (e.g., gastric balloons, duodenal jejunal bypass liners, and vagus nerve blocking devices) for obesity are not intended to be included as services on this line or any other line on the Prioritized List.”

That final bolded sentence is the canonical Oregon regulatory anchor for GLP-1 AOM coverage exclusion. It is broader than any pharmacy-benefit regulation — it applies to pharmacological treatments for obesity on any line of the Prioritized List, not merely on Line 317. Its mechanism is an evidence-review-commission guideline note, not a pharmacy administrator’s rule.

The Prioritized List is updated quarterly by HERC through public meetings. Any modification of Guideline Note 5 to allow AOM pharmacotherapy would require a HERC review and adoption of a revised list — a deliberate, public, evidence-based process distinct from agency rulemaking.

The regulatory bridge between the Prioritized List and the pharmacy benefit is OAR 410-121-0040, which provides verbatim: “Each drug shall be prescribed for conditions funded by the Oregon Health Plan (OHP) in a manner consistent with the Health Evidence Review Commission (HERC) Prioritized List.” This rule ties Guideline Note 5’s exclusion directly to pharmacy benefit adjudication.

Why Oregon Is Structurally Unique in the 50-State Series

Of the 29 states documented in this series, every other state that excludes AOM pharmacotherapy does so through a pharmacy-benefit regulation — a rule in the state administrative code governing Medicaid pharmaceutical benefits. Oregon is the only exception:

• CO (Pattern #27) anchors at 10 CCR 2505-10 § 8.800.4.B.2.a — a pharmacy benefit code rule listing “Agents when used for anorexia or weight loss” as excluded.
• OK (Pattern #24) anchors at OAC 317:30-5-72.1(1)(D) — a pharmacy benefit rule excluding “Drugs prescribed for weight gain or loss.”
• NJ (Pattern #11) anchors at N.J.A.C. 10:51-1.13(a)(2) — a pharmacy benefit regulation explicit exclusion of weight-loss drugs.
• WA (Pattern #14) anchors at WAC 182-530-2100(1)(b)(i) — a Washington Administrative Code pharmacy provision.
• IL (Pattern #5) anchors at 89 IAC § 140.441(b) — an administrative code rule excluding “anorectic drugs.”
• IN (Pattern #16) anchors at 405 IAC 5-24-3(b)(1) — a code provision excluding anorectic and anti-obesity drugs.

Oregon’s operative exclusion sits in a different institutional layer entirely: the HERC Prioritized List Guideline Note 5, which is an evidence-based coverage guideline maintained by an independent commission under the 1989 Oregon Basic Health Services Act. The Prioritized List is Oregon’s distinctive Medicaid coverage innovation — the only state in the U.S. that uses a ranked, evidence-reviewed list of condition-treatment pairs as the primary coverage policy mechanism.

This structural difference has two important implications. First, the path to changing Oregon’s AOM policy runs through HERC — an evidence-review-commission process — rather than through a pharmacy administrator or legislative mandate alone. Second, the exclusion is not merely a regulatory judgment about cost; it reflects HERC’s ongoing determination that pharmacological treatment for obesity, at this time, does not meet the evidence standard for inclusion on the Prioritized List on competitive terms with behavioral interventions and bariatric surgery.

The KFF January 2026 state tracker does not classify Oregon among the 13 covering states (DE, KS, MA, MI, MN, MS, MO, NC, RI, TN, UT, VA, WI). Oregon’s three FDA-label carve-outs operate as exceptions to the categorical Guideline Note 5 bar, not as general chronic-weight-management coverage.

Wegovy CV PA Criteria: Established Cardiovascular Disease Pathway

The Weight Management Drugs PA Criteria document at OregonPDL.org establishes coverage for semaglutide (Wegovy) when prescribed for cardiovascular risk reduction. The verbatim Table 3 notation:

“Table 3. Evidence-Supported Indications

Note: Drugs prescribed for only weight management (overweight or obesity) are NOT currently covered

Drug: Semaglutide
Indications:
• Established cardiovascular disease (e.g., history of myocardial infarction, stroke, or symptomatic peripheral arterial disease) (tablets or injection)
• Metabolic dysfunction-associated steatohepatitis (MASH) with stage 2 or 3 fibrosis in adults 18 years and older* (injection only)”

The operational gate for the CV indication is at Steps #13–16 of the PA decision tree. Members must first pass Steps #1–12 (BMI documentation, lifestyle modification engagement, EPSDT eligibility check, and the canonical adult-deny step at #12). For members who reach Step #13 with a Table 3–qualifying indication:

“14. Is there documentation of a type 2 diabetes diagnosis?
Yes: Go to #16.   No: Go to #15.

15. Has the patient been screened for diabetes within the past year and do screening results indicate they do not have diabetes (e.g., HbA1c <6.5% or fasting blood glucose <126 mg/dl (7 mmol/L))?
Yes: Go to #16.   No: Pass to RPh; Deny; medical appropriateness. Recommend screening and if positive recommend a GLP-1 RA indicated for glucose lowering (see GLP-1 RA/GIP RA PA criteria)”

Step #15 is the diabetes-screening gate. Members with undetected T2DM are routed to the diabetes PA pathway rather than the CV carve-out. This matches the FDA label for Wegovy, which is indicated for CV risk reduction in adults with obesity or overweight who do not have type 2 diabetes.

CareOregon layered criteria for Wegovy CV. CareOregon (administrator for Health Share of Oregon Tri-County and Columbia Pacific CCO regions) adds a CCO-specific age ≥ 45 requirement not present in the OHA FFS criteria. The CareOregon verbatim Wegovy CV criteria (Prevention of Secondary Cardiovascular Events, Initial Criteria) read:

“1. Is the request for the indication of reducing the risk of major cardiovascular events in an adult with established cardiovascular disease and either obesity or overweight?
If yes: Continue to #2.   If no: Do not approve. Medications for purposes of weight loss not covered in adults.

2. Has the member been screened for diabetes in the past 12 months and results show the member does not have diabetes (such as A1c <6.5% or fasting blood glucose <126 mg/dL)?
If yes: Continue to #3.   If no: Do not approve.

3. Is the member 45 years of age or older?
If yes: Continue to #4.   If no: Do not approve.

4. Does the member have a BMI of 27 kg/m² or greater?
If yes: Continue to #5.   If no: Do not approve.

5. Does the member have established cardiovascular disease by at least one of the following?
a. History of myocardial infarction: Defined as documentation of myocardial necrosis (such as changes in cardiac biomarkers) and supporting evidence from clinical presentation, electrocardiographic changes or coronary artery imaging.
b. History of stroke (ischemic or hemorrhagic) with confirmation of stroke by imaging.
c. Symptomatic peripheral arterial disease with evidence of one of the following: intermittent claudication with ankle-brachial index (ABI) < 0.85 (at rest), or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease.
If yes: Continue to #6.   If no: Do not approve.”

The CareOregon age ≥ 45 requirement is a CCO-specific tightening that applies in Clackamas, Multnomah, and Washington counties (Health Share of Oregon) plus Clatsop, Columbia, and Tillamook counties (Columbia Pacific CCO). Members in other CCO regions follow the OHA FFS criteria, which do not include an age minimum.

Authorization duration (all CV pathway approvals): Up to 6 months initial; renewal up to 12 months with evidence of BMI reduction ≥ 5% or maintained weight loss, adherence attestation, and continued CV-indication prescribing.

Wegovy/Liraglutide MASH PA Criteria — and Oregon’s August 2024 Early Adoption of Liraglutide MASH

Oregon’s MASH coverage story has two chapters. The first chapter predates the FDA.

Chapter 1 — August 2024: Oregon’s P&T Committee and DURM reviewed medications for MASH at the August 2024 P&T meeting, examined FDA-approved resmetirom and available phase 2 trial data for GLP-1 receptor agonists, and created an off-label coverage pathway for semaglutide and liraglutide based on compendial designations and phase 2 evidence. This predated the FDA’s approval of Wegovy for MASH by one full year. The February 5, 2026 P&T meeting packet documents this history verbatim:

“The Oregon Health Plan (OHP) fee for service (FFS) program previously reviewed medications for metabolic dysfunction-associated steatohepatitis (MASH) in August of 2024, including the Food and Drug Administration (FDA) approved agent resmetirom and available phase 2 studies for glucagon-like peptide-1 receptor agonists (GLP1-RA) and dual GLP-1 RA/glucose-dependent insulinotropic polypeptides (GIP) agonists. Based on review of evidence and compendial designations at that time, a pathway for off-label coverage of MASH was created for semaglutide and liraglutide.”

Chapter 2 — February 5, 2026 P&T meeting: Semaglutide received FDA expanded indication for MASH in noncirrhotic adult patients with moderate to advanced liver fibrosis (F2 and F3) in August 2025. At the February 5, 2026 P&T meeting, DURM presented Agenda Item C — “Wegovy® (semaglutide) Prior Authorization for MASH” — and the Committee formalized PA criteria implementing March 1, 2026. The meeting Plain Language Summary:

“Semaglutide (Wegovy®) in Metabolic Dysfunction-Associated Steatohepatitis

Plain Language Summary:
• The Food and Drug Administration recently approved a medicine called semaglutide (WEGOVY) for adult patients who have metabolic dysfunction-associated steatohepatitis without irreversible scarring (cirrhosis) of the liver.
• In people with metabolic dysfunction-associated steatohepatitis who do not have irreversible severe scarring of the liver (e.g., cirrhosis), semaglutide reduced scarring (e.g., fibrosis) and other signs of liver disease in some patients who took this medicine for almost one and a half years (72 weeks).
• The Drug Use Research and Management group recommends continuing to require prior authorization for semaglutide. Prior authorization means providers must explain why someone needs semaglutide before Medicaid will pay for it.”

The Committee’s verbatim Conclusions on the supporting evidence:

“Based on the interim analysis of a single, large, double-blind, placebo-controlled, multicenter RCT, there is moderate quality evidence that semaglutide resolves steatohepatitis without worsening fibrosis (number needed to treat [NNT] = 4) and reduces fibrosis without worsening steatohepatitis (NNT = 7) after 72 weeks of treatment at the weekly 2.4 mg dose of semaglutide. Part 2 of this RCT will evaluate if cirrhosis free survival is improved over 240 weeks of treatment. Potential unblinding due to gastrointestinal side effects and uneven attrition between groups already present at 72 weeks may complicate interpretation of longer-term results.”

Operative MASH criteria (verbatim Table 3 footnote and narrative text from Weight Management Drugs PA Criteria document):

“* MASH Requirements:
• Diagnosis by liver biopsy OR all of the following:
  o documentation that the patient does NOT have ongoing or recent (within 2 years) significant alcohol use or chronic or active viral hepatitis. Significant alcohol use can be patient-specific but is typically defined as greater than 21 drinks/week (or >30 g/day) in men and greater than 14 drinks/week (or >20 g/day) in women.
  o provider attestation or documentation that other causes of hepatic steatosis are not suspected based on patient history/presentation or have been ruled out. Examples of other secondary causes of hepatic steatosis include, but are not limited to, Wilson’s disease, lipodystrophy, abetalipoproteinemia, medications (e.g., amiodarone, methotrexate, tamoxifen, corticosteroids).
  o documentation that the patient has, or is receiving drug treatment for, at least 3 of the 5 metabolic risk factors associated with MASH. Risk factors include:
    ▪ Overweight or obesity or increased waist circumference (BMI ≥ 25 kg/m² or ethnicity adjusted equivalent)
    ▪ Hypertension
    ▪ Type 2 diabetes mellitus
    ▪ Hypertriglyceridemia
    ▪ Decreased level of high density lipoprotein (HDL)
• fibrosis stage 2 or 3 as shown by appropriate diagnostic test within past 24 months [appropriate tests may include biopsy, vibration controlled transient elastography (VCTE), magnetic resonance elastography (MRE), enhanced liver fibrosis test (ELF)]
• medication being ordered by, or in consultation with, a hepatologist or gastroenterologist”

CareOregon’s MASH criteria operationalize specific imaging thresholds: VCTE 8–15 kPa, MRE 3.1–4.4 kPa, or ELF 9.2–10.5 kPa. CareOregon also excludes concurrent use of Wegovy with Rezdiffra (resmetirom) — a CCO-specific restriction.

Critical coverage note: Wegovy MASH coverage at OHP is for the injection only — not the oral tablet. The Table 3 notation reads “(injection only)” for the MASH indication. The oral Wegovy tablet is available only under the CV carve-out (which reads “(tablets or injection)”). Liraglutide MASH coverage uses the same diagnostic criteria as Wegovy injection MASH. Note that liraglutide for chronic weight management (Saxenda) is not covered for adults — only liraglutide for MASH under these specific PA criteria.

The OHA PA criteria document’s verbatim note on liraglutide scope:

“Note: Semaglutide is not currently covered for adults who do not have established cardiovascular disease, metabolic dysfunction-associated steatohepatitis (MASH), or type 2 diabetes. Tirzepatide is not currently covered for adults who do not have established obstructive sleep apnea or type 2 diabetes. Liraglutide is not covered for adults who do not have type 2 diabetes or MASH.”

Zepbound OSA PA Criteria: Moderate-to-Severe Obstructive Sleep Apnea

Zepbound (tirzepatide) is the only preferred (PDL Status Y) agent in the Oregon Weight Management Drugs class. The Y status reflects Zepbound’s FDA-approved OSA indication; it does not mean Zepbound is available without prior authorization for weight management. All Zepbound prescriptions still route through the Weight Management Drugs PA criteria.

The verbatim OSA gate from the PA decision tree at Steps #16–17:

“16. Is the request for tirzepatide (ZEPBOUND)?
Yes: Go to #17.   No: Approve for up to 6 months

17. Does the patient have obesity (BMI of 30 kg/m² or greater) and moderate to severe obstructive sleep apnea (OSA)?
• Moderate OSA is defined as an apnea-hypopnea index (AHI) of 15 events/hour or more
• Severe OSA is defined as an AHI of 30 events/hour or more
Yes: Approve tirzepatide (ZEPBOUND) for up to 6 months    No: Pass to RPh. Deny; medical appropriateness.”

The OHA criteria require BMI ≥ 30 and AHI ≥ 15. The PA decision tree does not explicitly list a PAP-therapy-failure requirement at the FFS level, though the Weight Management Drugs PA criteria Goals statement specifies “engagement in weight-management lifestyle modification program in addition to pharmacotherapy.” CareOregon’s CCO-level OSA criteria add a PAP therapy maximization step:

“Obstructive Sleep Apnea
Initial Criteria

1. Is the request for Zepbound?
If yes: Continue to #2.   If no: Do not approve.

2. Does the member have a diagnosis of type 2 diabetes?
If yes: Do not approve.   If no: Continue to #3.

3. Does the member have a BMI of 30 kg/m² or greater?
If yes: Continue to #4.   If no: Do not approve.

4. Does the member have confirmation of a diagnosis of moderate to severe obstructive sleep apnea via polysomnography?
If yes: Continue to #5.   If no: Do not approve.

5. Has the member fully maximized the use of positive airway pressure therapy; or has a documented inability to tolerate it?
If yes: Continue to #6.   If no: Do not approve.”

CareOregon Step #2 adds a T2DM exclusion gate specific to the OSA indication: members with T2DM are routed to Mounjaro via the T2DM PA pathway rather than the Zepbound OSA carve-out. This mirrors the OHA note “Tirzepatide is not currently covered for adults who do not have established obstructive sleep apnea or type 2 diabetes” but operationalizes the T2DM split more explicitly.

For the renewal criteria, the PA criteria document requires at Step #6: “Has the patient lost or maintained a BMI reduction of 5% or more?” and at Step #8 continued engagement in a lifestyle modification program. Renewal authorization extends up to 12 months.

Foundayo (Orforglipron) on the PDL With No Defined PA Criteria: A Unique Early-Adoption Signal

The Oregon Weight Management Drugs PDL class (OregonPDL.org, cid=1057) includes the following verbatim entry:

“orforglipron calcium    FOUNDAYO    TABLET    [PDL Status: blank]    Pharmacy PA”

Foundayo (orforglipron) is the FDA-approved oral GLP-1 receptor agonist from Eli Lilly, approved in 2025 for chronic weight management in adults. The OregonPDL.org listing shows Pharmacy PA required but no defined New Drug Evaluation date — meaning the P&T Committee has not yet formally reviewed and adopted PA criteria specific to orforglipron. The PDL status is blank (not Y or N), which under the OregonPDL.org legend means “the class or specific drug has not been reviewed for PDL placement.”

The practical implication: a Foundayo prescription for an adult OHP member for chronic weight management will route through the Weight Management Drugs PA criteria and will be denied at Step #12 (“drugs are not covered by OHP for adults when indicated for weight loss”). No Foundayo coverage pathway exists for adult weight management under current OHP policy.

The significance is nevertheless notable: Oregon is the first state in the 29-state series to list Foundayo (orforglipron) on its AOM PDL class. This positions OHP to adopt Foundayo PA criteria for non-weight-loss indications — such as cardiovascular risk reduction or MASH, if and when those indications receive FDA approval — without requiring a new class-creation rulemaking. The PDL infrastructure is already in place; only a P&T Committee New Drug Evaluation is needed to operationalize criteria.

For comparison: Colorado (Pattern #27) does not list Foundayo on its Weight Management Drugs PDL class. Oklahoma (Pattern #24) does not list Foundayo on the OHCA PDL or DUR board criteria for any indication. Oregon’s proactive PDL listing of Foundayo is consistent with the same evidence-driven posture that led Oregon to cover liraglutide MASH off-label in August 2024 before the FDA approved that indication.

OHA Pharmacy Services FFS Architecture: No Third-Party PBM

Oregon is one of a small number of states in the 50-state series that does not contract a third-party pharmacy benefit manager (PBM) for its Medicaid FFS pharmacy program. Unlike Colorado (MedImpact effective April 2026), Texas (Acentra), California (Magellan/Medi-Cal Rx), New York (NYRx), or Oklahoma (Pharmacy Management Consultants/OU), Oregon’s OHA Pharmacy Services unit administers the FFS pharmacy benefit directly.

The architectural split is:

• OHA Pharmacy Services: FFS pharmacy claims processing; operational PA adjudication; administers the Oregon Pharmacy Call Center.
• DURM at Oregon State University College of Pharmacy: P&T Committee administration; clinical drug class reviews; new drug evaluations; PA criteria development; DUR functions; the Oregon State Drug Review newsletter; orpdl.org maintenance.

The Oregon Pharmacy Call Center is the primary operational contact for provider PA requests:

• Phone: 888-202-2126
• Email: dmap.rxquestions@oha.oregon.gov
• PA Form: OHP 3978 (at sharedsystems.dhsoha.state.or.us)

DURM’s operational contact (for clinical criteria queries, P&T meeting inquiries, and New Drug Evaluation requests):

• Phone: 503-947-5220
• Fax: 503-947-1119
• Mailing address: 500 Summer Street NE, E35, Salem, OR 97301-1079

The PDL is maintained at OregonPDL.org (run by DURM/OSU under OHA contract). The regulatory authority for the PDL is OAR 410-121-0030, which provides verbatim:

“The PMPDP is created and provided for under Senate Bill 819 (2001). The Authority shall maintain a list of the most cost-effective drugs available for the OHP and shall update it quarterly. The Authority shall include drugs on the PMPDP PDL using the recommendations of the Pharmacy and Therapeutics Committee.”

Member cost-sharing: OHP eliminated drug copays in 2017. There is no member financial barrier to accessing formulary drugs; all gatekeeping is through PA criteria.

The absence of a third-party PBM has an operational consequence for providers: PA requests go directly to the Oregon Pharmacy Call Center rather than to a contracted PBM help desk. The turnaround standard for PA responses is established in OAR 410-121-0030, which provides that the Authority shall approve an exception “where the prescriber requests an exception and fails to receive a report of PA status within 24 hours.”

DURM at Oregon State University College of Pharmacy: The 4th State-University PA Infrastructure in the Series

The Oregon P&T Committee is administered by the Drug Use Research and Management (DURM) group at Oregon State University College of Pharmacy. This is not the Oregon Health & Science University (OHSU). DURM’s primary operational offices are in Salem at OHA (500 Summer Street NE, E35); the OSU College of Pharmacy also has campuses in Portland (OHSU Robertson Life Sciences Building) and Corvallis, but DURM personnel at those locations are OSU College of Pharmacy faculty, not OHSU faculty.

The DURM mission statement, verbatim:

“At the Drug Use Research and Management (DURM) group, our mission is to promote safe, effective, innovative, and financially sustainable drug policies through dedicated service, comprehensive research, and high-quality education. As a part of the Oregon State University College of Pharmacy, we partner with the Oregon Health Authority (OHA) to provide essential support and expertise for their pharmacy programs. Our responsibilities include administering the Oregon Pharmacy & Therapeutics (P&T) Committee, evaluating drug utilization, offering drug information and policy analysis, and providing Medicaid provider education and drug therapy consultations.”

The Oregon P&T Committee itself was created by Oregon Laws 2011, chapter 720 (HB 2100), which abolished the prior Drug Use Review Board. The P&T Committee is an 11-member advisory body of physicians, pharmacists, and consumer representatives. Under OAR 410-121-0111:

“The committee shall make recommendations to the Authority, subject to approval by the Director or the Director’s designee, for drugs to be included on any PDL adopted by the Authority.”

Oregon’s DURM/OSU model is the fourth state-university PA infrastructure documented in the 50-state series:

• OK (Pattern #24): Pharmacy Management Consultants (PMC) at the University of Oklahoma Health Sciences Center — OU/PMC is a wholly-owned OU subsidiary and handles all pharmacy benefit operations for SoonerCare FFS.
• LA (Pattern #28): University of Louisiana at Monroe (ULM) College of Pharmacy Prior Approval Desk — ULM administers FFS PA adjudication for the LDH FFS pharmacy benefit.
• CO (Pattern #27): University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) — administers the DUR Board (SSPPS.co-dur@cuanschutz.edu); DUR Board meets quarterly.
• OR (Pattern #29): Oregon State University College of Pharmacy (DURM) — administers the P&T Committee; produces PA criteria; runs OregonPDL.org; provides DUR functions. Distinct from OU/PMC and ULM in that DURM handles clinical and DUR functions while OHA Pharmacy Services handles operational PA processing.

The 15 Coordinated Care Organizations

Oregon Health Plan delivers care through CCOs under CCO 2.0 contracts with OHA. As of 2026-05-10, the OHA CCO page lists 15 CCOs covering all Oregon counties:

1. Advanced Health — Coos and Curry counties
2. AllCare CCO — Curry, Josephine, Jackson, and part of Douglas counties
3. Cascade Health Alliance — parts of Klamath County
4. Columbia Pacific Coordinated Care Organization — Clatsop, Columbia, and Tillamook counties
5. Eastern Oregon Coordinated Care Organization — Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa, and Wheeler counties
6. Health Share of Oregon — Clackamas, Multnomah, and Washington counties
7. InterCommunity Health Network CCO — Benton, Lincoln, and Linn counties
8. Jackson Care Connect — Jackson County
9. PacificSource Community Solutions — Central Oregon — Deschutes, Crook, Jefferson, and part of Klamath County
10. PacificSource Community Solutions — Columbia Gorge — Hood River and Wasco counties
11. PacificSource Community Solutions — Marion/Polk — Marion and Polk counties
12. Trillium Community Health Plan — Southwest — Lane County; western Linn and Douglas counties
13. Trillium Community Health Plan — Tri-County — Clackamas, Multnomah, and Washington counties
14. Umpqua Health Alliance — most of Douglas County
15. Yamhill Community Care — Yamhill County, parts of Washington and Polk counties

CCOs administer pharmacy benefits under their OHA contracts. Most CCO PA criteria substantially mirror the OHA FFS PDL/PA architecture with layered CCO-specific PA forms. Two CCOs with verified primary-source PA criteria are documented below.

CareOregon (Health Share of Oregon & Columbia Pacific CCO)

CareOregon administers the pharmacy benefit for Health Share of Oregon (Clackamas, Multnomah, Washington — CCO #6 above) and Columbia Pacific CCO (Clatsop, Columbia, Tillamook — CCO #4). The CareOregon PA criteria document for GLP-1 & GIP Agonist Drugs for Non-Diabetes Indications (Revised 01/08/2026; Updated 02/01/2026) covers four pathways: Chronic Weight Management–Pediatrics, Noncirrhotic MASH, Obstructive Sleep Apnea, and Prevention of Secondary Cardiovascular Events.

Verbatim adult exclusion language from the pediatric pathway’s Step #1:

“If no: Deny for Guideline Note. Medications for purposes of weight loss not covered in adults.”

This directly references the HERC Guideline Note mechanism, confirming that CareOregon’s adult exclusion is anchored at the same Guideline Note 5 authority as the OHA FFS policy.

Trillium Community Health Plan (Southwest and Tri-County)

Trillium Community Health Plan (a Centene subsidiary) administers benefits for Trillium Community Health Plan—Southwest (Lane, western Linn and Douglas — CCO #12) and Trillium Community Health Plan—Tri-County (Clackamas, Multnomah, Washington — CCO #13). Trillium’s Clinical Policy OR.CP.PMN.1015 (“Weight Management Drugs for Youth”, effective 07.01.24, last review 06.25) carries the cleanest CCO-level articulation of the adult AOM exclusion in the series:

“Use of medications for the treatment of weight loss in adults (age ≥21 years of age) is a benefit exclusion under the Oregon Health Plan. The only exception are members with Young Adults with Special Health Care Needs (YSHCN) coverage and was born in or after the year 2004.”

The Trillium policy is titled “Weight Management Drugs for Youth” specifically because adult weight-loss pharmacotherapy is a benefit exclusion — the policy exists only to operationalize the EPSDT/YSHCN pediatric carve-in pathways. Trillium’s pediatric Weight Management criteria cover members age 12–20 with BMI ≥ 30 or ≥ 27 with cardiovascular risk indicators, subject to lifestyle modification documentation and prior Qsymia trial failure (for Wegovy). The Genetic Obesity Disorders pathway covers setmelanotide for POMC/PCSK1/LEPR deficiency or BBS in members age ≥ 6 through 20 (or through 25 with YSHCN).

Other 13 CCOs

AllCare CCO, PacificSource Community Solutions (Central Oregon, Columbia Gorge, Marion/Polk), Advanced Health, Cascade Health Alliance, Eastern Oregon CCO, InterCommunity Health Network CCO, Jackson Care Connect, Umpqua Health Alliance, and Yamhill Community Care substantially mirror the OHA PDL PA architecture with their own administrative PA forms. The OHA Weight Management Drugs PA criteria document is the primary operational standard. Direct PA criteria documents for these 13 CCOs were not independently verified as of 2026-05-10; members should confirm with their CCO’s pharmacy department for CCO-specific nuances [per OHA CCO 2.0 contract framework].

February 5, 2026 P&T Meeting: Wegovy MASH Criteria Adoption

The February 5, 2026 Oregon Pharmacy and Therapeutics Committee meeting (Salem, OR) included Agenda Item C: formal adoption of Wegovy MASH PA criteria following the August 2025 FDA expanded approval of semaglutide for MASH. Implementation was set for March 1, 2026.

The meeting packet (10.6 MB PDF; 15,553 lines) documents that DURM staff member Sara Fletcher PharmD MPH BCPS presented a complete evidence review of the ESSENCE trial (NCT04822181, the Phase 3 pivotal trial). Key trial data presented at the meeting:

• Single large double-blind placebo-controlled multicenter RCT; interim analysis at 72 weeks.
• NNT = 4 for semaglutide resolving steatohepatitis without worsening fibrosis.
• NNT = 7 for semaglutide reducing fibrosis without worsening steatohepatitis.
• Part 2 of the trial will evaluate cirrhosis-free survival over 240 weeks.
• DURM Recommendation: “Update PA criteria for semaglutide (WEGOVY)” — operationalizing formal criteria for the August 2025 FDA approval.

The P&T Review history at the foot of the Weight Management Drugs PA Criteria document confirms: “P&T/DUR Review: 2/26 (SF); 4/25 (KS); 8/24 (SS/SF); 6/24 (KS) — Implementation: 3/1/26; 5/12/25; 9/1/24; 7/1/24.” The 8/24 review established the liraglutide MASH off-label pathway; the 2/26 review formalized the Wegovy MASH FDA-label pathway.

Appeals: Oregon Office of Administrative Hearings Pathway

Oregon Health Plan uses a two-tier appeals structure for pharmacy PA denials.

Tier 1: CCO-Level Appeal

The OHA Appeals and Hearings page provides verbatim:

“Your CCO must receive your appeal within 60 days from the date on the Notice of Adverse Benefit Determination.”

“Your CCO has 16 days to review their decision and any new information you or your provider send them. In some cases, the CCO may ask for another 14 days to complete the review.”

Members receiving a Notice of Adverse Benefit Determination for a Wegovy, Zepbound, or liraglutide PA denial should:

1. Obtain the written denial letter and the specific PA criterion the request failed.
2. Have the prescribing provider prepare a Letter of Medical Necessity (LOMN) addressing the verbatim PA criteria from the Weight Management Drugs PA Criteria document — citing the specific Table 3 indication (CV established disease, MASH F2/F3, or OSA AHI ≥ 15).
3. File the CCO appeal within 60 days of the denial notice, with LOMN and supporting documentation (imaging reports, cardiology notes, sleep study, lab results).
4. If the denial was for weight-loss-only (adult, age ≥ 21), the appeal must instead argue that the patient meets a Table 3 indication. A categorical Guideline Note 5 denial on weight-loss grounds cannot be successfully appealed on weight-loss grounds alone.

Tier 2: OHA Administrative Hearing

Verbatim from the OHA Appeals and Hearings page:

“You can ask OHA for an administrative hearing (also called a contested case hearing). You must do this within 120 days from the date on the Notice of Appeal Resolution.”

OHA Medical Hearings Unit contacts:

• Phone: 503-945-5785
• Email: OHAMedical.Hearings@odhsoha.oregon.gov
• Not in a CCO (FFS): 1-800-273-0557

The continuation-of-benefits provision is available: “If the notice is about a service you are already getting, you may be able to ask to keep getting the service” — but if the reviewer upholds the denial, the member may have to pay for services received during the appeal period. This continuation of benefits option is most relevant for members already receiving Wegovy or Zepbound under an approved PA who receive a renewal denial.

Administrative hearings are conducted by Administrative Law Judges (ALJs) at the Oregon Office of Administrative Hearings. An ALJ hearing on a Guideline Note 5 weight-loss-only denial will be sustained: Guideline Note 5 is a binding regulatory restriction, not a discretionary PA determination. The substantive appeal posture for a denied CV, MASH, or OSA PA is procedural — arguing that the PA reviewer failed to properly evaluate documentation of the covered indication.

How Oregon Compares: WA, CO, OK, MN as Closest Analogues

Oregon’s Pattern #29 designation reflects a distinctive combination of features. The four closest analogues from prior installments in the series:

WA (Pattern #14) — Pacific Northwest Triple-Carve-Out

Washington is the closest structural analogue on coverage architecture: both states have the same three FDA-label carve-outs (Wegovy CV + Wegovy MASH + Zepbound OSA), both exclude AOM for chronic weight management in adults, and neither contracts a third-party PBM for FFS pharmacy. The key difference: Washington anchors at WAC 182-530-2100(1)(b)(i) (a Washington Administrative Code pharmacy provision), while Oregon anchors at HERC Guideline Note 5 (an evidence-based coverage list). Washington has 5 MCOs (Apple Health managed care); Oregon has 15 CCOs. Washington has no Prioritized List analog. Oregon additionally covers liraglutide for MASH; Washington does not. See our Washington Medicaid Apple Health GLP-1 Coverage 2026: Pattern #14 for the verbatim WAC exclusion and Wegovy/Zepbound carve-out criteria.

CO (Pattern #27) — Mountain West Triple-Carve-Out

Colorado is the closest analogue on the “categorical exclusion + three FDA-label carve-outs” architecture. Both states have all three carve-outs. Key differences: CO anchors at 10 CCR 2505-10 § 8.800.4.B.2.a (pharmacy benefit code rule); OR anchors at HERC Guideline Note 5. CO uses MedImpact as PBM; OR has no third-party PBM. CO’s MASH carve-out is Wegovy injection only; OR’s covers Wegovy injection AND liraglutide. CO has 4 RAEs plus 1 MCO; OR has 15 CCOs. CO passed SB 25-048 (large-group commercial mandate with explicit Medicaid carve-out); Oregon has no equivalent statute. See our Colorado Medicaid GLP-1 Coverage 2026: Pattern #27 for the verbatim CCR exclusion and full PDL V1.1 criteria.

OK (Pattern #24) — Academic-Pharmacy DUR Analogue

Oklahoma is the closest analogue on the university-college-of-pharmacy DUR model: OR routes criteria development through DURM at OSU College of Pharmacy; OK routes operations through Pharmacy Management Consultants (PMC) at the University of Oklahoma Health Sciences Center. Key difference: OK’s PMC handles all pharmacy benefit operations; OR’s DURM handles only clinical/DUR functions while OHA Pharmacy Services handles operations. OK anchors at OAC 317:30-5-72.1(1)(D); OR anchors at HERC Guideline Note 5. OK has a fourth carve-out (Imcivree for monogenic obesity, covered for adults); OR’s Imcivree pathway is restricted to EPSDT/YSHCN. See our Oklahoma SoonerCare GLP-1 Coverage 2026: Pattern #24 for the verbatim OAC exclusion and the OU/PMC PA infrastructure.

MN (Pattern #20) — Dedicated Weight Management PDL Class

Minnesota is the closest analogue on the “dedicated Weight Management PDL class” architecture: both states have a named weight management drug class on their PDL. Critical difference: MN’s “Weight Management Agents” class has affirmative chronic-weight-management coverage; OR’s “Weight Management Drugs” class is gated by the categorical Guideline Note 5 exclusion. MN is on KFF’s January 2026 covering-states list; OR is not. Both states have Foundayo listed; OR added it first (no PA criteria yet in either state as of 2026-05-10).

What Oregon Health Plan Members Can Do in 2026

Oregon Health Plan members seeking GLP-1 coverage in 2026 have four operative pathways:

Pathway 1: Established Cardiovascular Disease (Wegovy CV)

Members with a documented history of myocardial infarction, ischemic or hemorrhagic stroke (with imaging confirmation), or symptomatic peripheral arterial disease (ABI < 0.85, or revascularization, or amputation), plus BMI ≥ 25 kg/m², plus negative diabetes screen within 12 months, qualify for the Wegovy CV PA pathway. Ask your prescriber to document the CVD event specifically, not just “cardiovascular risk factors.” Hypertension alone does not qualify. The PA request goes to the Oregon Pharmacy Call Center (888-202-2126) for FFS members, or to the CCO pharmacy department for CCO-enrolled members.

Pathway 2: Noncirrhotic MASH F2–F3 (Wegovy Injection or Liraglutide)

Members with biopsy-confirmed or imaging-confirmed MASH with F2 or F3 fibrosis, plus at least three of five metabolic risk factors, plus no active significant alcohol use or viral hepatitis, qualify for the MASH PA pathway with prescriber involvement of a hepatologist or gastroenterologist. Non-invasive diagnostic test options (with required thresholds): VCTE, MRE, or ELF. This pathway is distinct from the CV pathway — a member with MASH but no prior CVD event can still access Wegovy injection or liraglutide through the MASH criteria.

Pathway 3: Moderate-to-Severe OSA (Zepbound)

Members with polysomnogram-confirmed OSA (AHI ≥ 15), BMI ≥ 30, and failed or contraindicated PAP therapy qualify for the Zepbound OSA pathway. The polysomnography report is required documentation. PAP therapy trial documentation (or contraindication documentation) is required at the CCO level (confirmed by CareOregon criteria Step #5). Members with T2DM should use the Mounjaro T2DM PA pathway instead.

Pathway 4: EPSDT/YSHCN Pediatric Carve-In (Age < 21 or < 26 born on or after January 1, 2004)

Members under age 21 covered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, and members under 26 with YSHCN coverage born in or after 2004, may receive case-by-case PA review for weight management medications for severe obesity. The EPSDT pathway requires BMI ≥ 35 or ≥ 120% of the 95th percentile, maximized behavioral interventions (motivational interviewing plus family-based counseling delivering ≥ 26 hours over 3–12 months), and for Wegovy specifically, prior Qsymia trial failure (per CareOregon criteria).

What Patients Cannot Obtain Under Current OHP Policy

Adult OHP members (age ≥ 21, not YSHCN-eligible) cannot obtain coverage under OHP for GLP-1 receptor agonists or any other AOM for chronic weight management, regardless of BMI, regardless of obesity severity, and regardless of comorbidities (except the specific covered indications above). The Guideline Note 5 exclusion is categorical. Saxenda (liraglutide for weight management), Contrave, Qsymia, orlistat, phentermine, and Foundayo are all on the Oregon Weight Management Drugs PDL — but all are operationally denied for adult chronic-weight-management indications by Guideline Note 5.

No active 2025–2026 Oregon legislation has been enacted that would extend OHP coverage to AOM pharmacotherapy for chronic weight management in adults. The 2025 Oregon Legislature received an informational “Addressing Obesity in Oregon” presentation from AON, but no bill was introduced or enacted on this topic as of 2026-05-10.

Sources