§ 7310. Health insurance plans--Step therapy protocol--Requirements
Oklahoma Statutes AnnotatedTitle 63. Public Health and SafetyEffective: November 1, 2019
Effective: November 1, 2019
63 Okl.St.Ann. § 7310
§ 7310. Health insurance plans--Step therapy protocol--Requirements
2. “Health insurance plan” means any individual or group health insurance policy, medical service plan, contract, hospital service corporation contract, hospital and medical service corporation contract, fraternal benefit society or health maintenance organization, municipal group-funded pool, the Oklahoma Medicaid Program and the state health care benefits plan that provides medical, surgical or hospital expense coverage. For purposes of this section, “health insurance plan” also includes any utilization review organization that contracts with a health insurance plan provider;
3. “Medical necessity” means that, under the applicable standard of care, a health service or supply is appropriate to improve or preserve health, life or function, to slow the deterioration of health, life or function or for the early screening, prevention, evaluation, diagnosis or treatment of a disease, condition, illness or injury;
B. For any health insurance plan that is delivered, issued for delivery, amended or renewed on or after January 1, 2020, and that utilizes a step therapy protocol, a health carrier, health benefit plan or utilization review organization shall use recognized, evidence-based and peer-reviewed clinical practice guidelines when establishing any step therapy protocol, when such guidelines are available.
C. 1. For any health insurance plan that is delivered, issued for delivery, amended or renewed on or after January 1, 2020, and that restricts coverage of a prescription drug for the treatment of any medical condition pursuant to a step therapy protocol, the health insurance plan provider shall provide to the prescribing healthcare provider and patient access to a clear, convenient and readily accessible process to request a step therapy exception. Any health insurance plan provider that utilizes a step therapy protocol shall make such process to request a step therapy exception accessible on the health insurance plan provider's website.
D. A health insurance plan provider shall respond to a request for a step therapy exception, or any appeal therefor, within seventy-two (72) hours of receipt of the request or appeal. If a patient's prescribing healthcare provider indicates that exigent circumstances exist, the health insurance plan provider shall respond to such a request or appeal within twenty-four (24) hours of receipt of the request or appeal. If the health insurance plan provider fails to respond within the required time, the step therapy exception or appeal shall be deemed granted. Upon granting a step therapy exception, the health insurance plan provider shall authorize coverage for and dispensation of the prescription drug prescribed by the patient's healthcare provider.
Credits
Laws 2019, c. 69, § 1, eff. Nov. 1, 2019.
63 Okl. St. Ann. § 7310, OK ST T. 63 § 7310
Current with emergency effective legislation through Chapter 3 of the Second Regular Session of the 59th Legislature (2024). Some sections may be more current, see credits for details.
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