{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-7310","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-7310","heading":"Health insurance plans – Step therapy protocol -","body":"Requirements.\n\nA. As used in this section:\n\n1. \"Clinical practice guidelines\" means a systematically\n\ndeveloped statement to assist decision-making by healthcare\n\nproviders and patients about appropriate healthcare or specific\n\nclinical circumstances and conditions;\n\n2. \"Health insurance plan\" means any individual or group health\n\ninsurance policy, medical service plan, contract, hospital service\n\ncorporation contract, hospital and medical service corporation\n\ncontract, fraternal benefit society or health maintenance\n\norganization, municipal group-funded pool, the Oklahoma Medicaid\n\nProgram and the state health care benefits plan that provides\n\nmedical, surgical or hospital expense coverage. For purposes of\n\nthis section, \"health insurance plan\" also includes any utilization\n\nreview organization that contracts with a health insurance plan\n\nprovider;\n\n3. \"Medical necessity\" means that, under the applicable\n\nstandard of care, a health service or supply is appropriate to\n\nimprove or preserve health, life or function, to slow the\n\ndeterioration of health, life or function or for the early\n\nscreening, prevention, evaluation, diagnosis or treatment of a\n\ndisease, condition, illness or injury;\n\n4. \"Step therapy protocol\" means a protocol or program that\n\nestablishes a specific sequence in which prescription drugs for a\n\nspecified medical condition that are medically appropriate for a\n\nparticular patient are covered by a health insurance plan;\n\n5. \"Step therapy exception\" means a process by which a step\n\ntherapy protocol is overridden in favor of immediate coverage of the\n\nhealthcare provider's selected prescription drug;\n\n6. \"Utilization review organization\" means an entity that\n\nconducts utilization review, not including a health insurance plan\n\nprovider performing utilization review for the provider's own health\n\ninsurance plan; and\n\n7. \"Pharmaceutical sample\" means a unit of a prescription drug\n\nthat is not intended to be sold and is intended to promote the sale\n\nof the drug.\n\nB. For any health insurance plan that is delivered, issued for\n\ndelivery, amended or renewed on or after January 1, 2020, and that\n\nutilizes a step therapy protocol, a health carrier, health benefit\n\nplan or utilization review organization shall use recognized,\n\nevidence-based and peer-reviewed clinical practice guidelines when\n\nestablishing any step therapy protocol, when such guidelines are\n\navailable.\n\nC. 1. For any health insurance plan that is delivered, issued\n\nfor delivery, amended or renewed on or after January 1, 2020, and\n\nthat restricts coverage of a prescription drug for the treatment of\n\nany medical condition pursuant to a step therapy protocol, the\n\nhealth insurance plan provider shall provide to the prescribing\n\nhealthcare provider and patient access to a clear, convenient and\n\nreadily accessible process to request a step therapy exception. Any\n\nhealth insurance plan provider that utilizes a step therapy protocol\n\nshall make such process to request a step therapy exception\n\naccessible on the health insurance plan provider's website.\n\n2. A health insurance plan shall grant a requested step therapy\n\nexception if the submitted justification of the prescribing provider\n\nand supporting clinical documentation, if needed, is completed and\n\nsupports the statement of the provider that:\n\na. the required prescription drug is contraindicated or\n\nwill likely cause an adverse reaction or physical or\n\nmental harm to the patient,\n\nb. the required prescription drug is expected to be\n\nineffective based on the known clinical\n\ncharacteristics of the patient and the known\n\ncharacteristics of the prescription drug,\n\nc. the patient has tried the required prescription drug\n\nwhile under the patient's current or a previous health\n\ninsurance plan and such prescription drug was\n\ndiscontinued due to lack of efficacy or effectiveness,\n\ndiminished effect or an adverse event,\nexpected to be\n\nineffective based on the known clinical\n\ncharacteristics of the patient and the known\n\ncharacteristics of the prescription drug,\n\nc. the patient has tried the required prescription drug\n\nwhile under the patient's current or a previous health\n\ninsurance plan and such prescription drug was\n\ndiscontinued due to lack of efficacy or effectiveness,\n\ndiminished effect or an adverse event,\n\nd. the required prescription drug is not in the best\n\ninterest of the patient, based on medical necessity,\n\nor\n\ne. the patient is stable on a prescription drug selected\n\nby the patient's healthcare provider for the medical\n\ncondition under consideration while on the patient's\n\ncurrent or a previous health insurance plan.\n\n3. A health insurance plan provider shall permit a patient to\n\nappeal any decision rendered on a request for a step therapy\n\nexception.\n\nD. A health insurance plan provider shall respond to a request\n\nfor a step therapy exception, or any appeal therefor, within\n\nseventy-two (72) hours of receipt of the request or appeal. If a\n\npatient's prescribing healthcare provider indicates that exigent\n\ncircumstances exist, the health insurance plan provider shall\n\nrespond to such a request or appeal within twenty-four (24) hours of\n\nreceipt of the request or appeal. If the health insurance plan\n\nprovider fails to respond within the required time, the step therapy\n\nexception or appeal shall be deemed granted. Upon granting a step\n\ntherapy exception, the health insurance plan provider shall\n\nauthorize coverage for and dispensation of the prescription drug\n\nprescribed by the patient's healthcare provider.\n\nE. This section shall not be construed to prevent a healthcare\n\nprovider from prescribing a prescription drug that is determined to\n\nbe medically appropriate.\n\nF. Nothing in this section shall be construed to authorize the\n\nuse of a pharmaceutical sample for the sole purpose of meeting the\n\nrequirements for a step therapy exception.\n\nG. Nothing in this section shall be construed to prevent the\n\nsubstitution of a drug in accordance with current statutes and\n\nregulations of this state.\n\nH. The Oklahoma Insurance Department and the Oklahoma Health\n\nCare Authority shall adopt rules necessary to implement and\n\nadminister this act prior to January 1, 2020.","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"1b7db307fa318a157e8af2419c91a4901dedda082bc39b7f18a6deb8e6866a66","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-7302","next":"us-ok/okla.-stat.-tit.-63-63-7320"},"notice":"GroundRules: Original legal text. Not legal advice."}