{"data":{"id":"us-ok/okla.-stat.-tit.-36-36-6570.50","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 36, § 36-6570.50","heading":"Definitions","body":"As used in this act:\n\n1. \"Adverse determination\" means a determination by a health\n\ncarrier, pharmacy benefits manager (PBM), or its designee\n\nutilization review entity that a prescription drug that is a covered\n\nbenefit has been reviewed and, based upon the information provided,\n\ndoes not meet the health plan's or PBM's requirements for medical\n\nnecessity, appropriateness, health care setting, level of care, or\n\neffectiveness, and the requested prescription drug or payment for\n\nthe prescription drug is therefore denied, reduced, or terminated as\n\ndefined by Section 6475.3 of Title 36 of the Oklahoma Statutes;\n\n2. \"Chronic condition\" means a condition that lasts one (1)\n\nyear or more and requires ongoing medical attention or limits\n\nactivities of daily living or both;\n\n3. \"Clinical criteria\" means the written policies, written\n\nscreening procedures, determination rules, determination abstracts,\n\nclinical protocols, practice guidelines, medical protocols, and any\n\nother criteria or rationale used by the utilization review entity to\n\ndetermine the necessity and appropriateness of prescription drugs;\n\n4. \"Emergency health care services\", with respect to an\n\nemergency medical condition as defined in 42 U.S.C.A., Section\n\n300gg-111, means:\n\na. a medical screening examination, as required under\n\nSection 1867 of the Social Security Act, 42 U.S.C.,\n\nSection 1395dd, or as would be required under such\n\nsection if such section applied to an independent,\n\nfreestanding emergency department, that is within the\n\ncapability of the emergency department of a hospital\n\nor of an independent, freestanding emergency\n\ndepartment, as applicable, including ancillary\n\nservices routinely available to the emergency\n\ndepartment to evaluate such emergency medical\n\ncondition, and\n\nb. within the capabilities of the staff and facilities\n\navailable at the hospital or the independent,\n\nfreestanding emergency department, as applicable, such\n\nfurther medical examination and treatment as are\n\nrequired under Section 1395dd of the Social Security\n\nAct, or as would be required under such section if\n\nsuch section applied to an independent, freestanding\n\nemergency department, to stabilize the patient,\n\nregardless of the department of the hospital in which\n\nsuch further examination or treatment is furnished, as\n\ndefined by 42 U.S.C.A., Section 300gg-111;\n\n5. \"Emergency Medical Treatment and Active Labor Act\" or\n\n\"EMTALA\" means Section 1867 of the Social Security Act and\n\nassociated regulations;\n\n6. \"Enrollee\" means an individual who is enrolled in a health\n\ncare plan, including covered dependents, as defined by Section\n\n6592.1 of Title 36 of the Oklahoma Statutes;\n\n7. \"Health care provider\" means any person or other entity who\n\nis licensed pursuant to the provisions of Title 59 or Title 63 of\n\nthe Oklahoma Statutes, or pursuant to the definition in Section 1-\n\n1708.1C of Title 63 of the Oklahoma Statutes;\n\n8. \"Health plan\" means a health benefit plan as defined by\n\nSection 6060.4 of Title 36 of the Oklahoma Statutes;\n\n9. \"Licensed mental health professional\" means:\n\na. a psychiatrist who is a diplomate of the American\n\nBoard of Psychiatry and Neurology,\n\nb. a psychiatrist who is a diplomate of the American\n\nOsteopathic Board of Neurology and Psychiatry, or\n\nc. a physician licensed pursuant to the Oklahoma\n\nAllopathic Medical and Surgical Licensure and\n\nSupervision Act or the Oklahoma Osteopathic Medicine\n\nAct;\n\n10. \"Medically necessary\" means drugs prescribed by a health\n\ncare provider that are:\n\na. appropriate for the symptoms and diagnosis or\n\ntreatment of the enrollee's condition, illness,\n\ndisease, or injury,\n\nb. in accordance with standards of good medical practice,\n\nc. not primarily for the convenience of the enrollee or\n\nthe enrollee's health care provider, and\n\nd. the most appropriate supply and prescription drug that\n\ncan safely be provided to the enrollee as defined by\nthat are:\n\na. appropriate for the symptoms and diagnosis or\n\ntreatment of the enrollee's condition, illness,\n\ndisease, or injury,\n\nb. in accordance with standards of good medical practice,\n\nc. not primarily for the convenience of the enrollee or\n\nthe enrollee's health care provider, and\n\nd. the most appropriate supply and prescription drug that\n\ncan safely be provided to the enrollee as defined by\n\nSection 6592 of Title 36 of the Oklahoma Statutes;\n\n11. \"Notice\" means communication delivered either\n\nelectronically or through the United States Postal Service or common\n\ncarrier;\n\n12. \"Pharmacist\" means a person licensed by the Board of\n\nPharmacy to engage in the practice of pharmacy;\n\n13. \"PBM\" means a pharmacy benefits manager as defined by\n\nSection 357 of Title 59 of the Oklahoma Statutes;\n\n14. \"Physician\" means an allopathic or osteopathic physician\n\nlicensed by the State of Oklahoma or another state to practice\n\nmedicine;\n\n15. \"Prior authorization\" means the process by which\n\nutilization review entities determine the medical necessity and\n\nmedical appropriateness of otherwise covered prescription drug prior\n\nto the dispensing of such prescription drug. The term shall include\n\n\"authorization\", \"pre-certification\", and any other term that would\n\nbe a reliable determination by a health benefit plan;\n\n16. \"Urgent prescription drug\" means a prescription drug with\n\nrespect to which the application of the time periods for making an\n\nurgent care determination, which, in the opinion of a physician with\n\nknowledge of the enrollee's medical condition:\n\na. could seriously jeopardize the life or health of the\n\nenrollee or the ability of the enrollee to regain\n\nmaximum function, or\n\nb. in the opinion of a physician with knowledge of the\n\nclaimant's medical condition, would subject the\n\nenrollee to severe pain that cannot be adequately\n\nmanaged without the care or treatment that is the\n\nsubject of the utilization review; and\n\n17. \"Utilization review entity\" means an individual or entity\n\nthat performs prior authorization for a health benefit plan as\n\ndefined by Section 6060.4 of Title 36 of the Oklahoma Statutes.","path":["OK Code","Title 36"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os36.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"8a9f2018ee1a2fe1592a0f19c75a28f58708497538dd8b4eec9e5eeba679847e","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-36-36-6570.5","next":"us-ok/okla.-stat.-tit.-36-36-6570.51"},"notice":"GroundRules: Original legal text. Not legal advice."}