{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-7330","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-7330","heading":"Process to request exception to treatment step therapy","body":"protocol — Circumstances requiring an exception.\n\nA. \"Health benefit plan\" means a plan as defined pursuant to\n\nSection 6060.4 of Title 36 of the Oklahoma Statutes, that provides\n\ncoverage for invasive or noninvasive mechanical ventilation to treat\n\nchronic respiratory failure consequent to chronic obstructive\n\npulmonary disease (CRF-COPD), requiring a step therapy protocol.\n\nB. \"Treatment step therapy protocol\" means a treatment\n\nutilization management protocol or program under which a group\n\nhealth plan or health insurance issuer offering group health\n\ninsurance coverage of respiratory care treatments requires a\n\nparticipant or beneficiary to try an alternative, plan-preferred\n\ntreatment and fail on this treatment before the plan or health\n\ninsurance issuer approves coverage for the non-preferred therapy\n\nprescribed by the beneficiary's medical provider.\n\nC. A health benefit plan shall:\n\n1. Implement a clear and transparent process for a participant\n\nor beneficiary, or the prescribing health care provider on behalf of\n\nthe participant or beneficiary, with CRF-COPD to request an\n\nexception to such a step therapy protocol, pursuant to subsection B\n\nof this section; and\n\n2. Where the participant or beneficiary or prescribing health\n\ncare provider's request for an exception to the treatment step\n\ntherapy protocols satisfies the criteria and requirements of\n\nsubsection D of this section, cover the requested treatment in\n\naccordance with the terms established by the health plan or coverage\n\nfor patient cost-sharing rates or amounts at the time of the\n\nparticipant's or beneficiary's enrollment in the health plan or\n\nhealth insurance coverage.\n\nD. The circumstances requiring an exception to a treatment step\n\ntherapy protocol, pursuant to a request under subsection C of this\n\nsection, are any of the following:\n\n1. Any treatments otherwise required under the protocol have\n\nnot been shown to be as effective as other available options in the\n\ntreatment of the disease or condition or the participant or\n\nbeneficiary, when prescribed consistent with clinical indications,\n\nclinical guidelines, or other peer-reviewed evidence;\n\n2. Delay of proven effective treatment would lead to severe or\n\nirreversible consequences, and the treatment initially required\n\nunder the protocol is reasonably expected to be less effective\n\nbased upon the documented physical or mental characteristics of the\n\nparticipant or beneficiary and the known characteristics of such\n\ntreatment;\n\n3. Any treatments otherwise required under the protocol are\n\ncontraindicated for the participant or beneficiary or have caused,\n\nor are likely to cause, based on clinical, peer-reviewed evidence,\n\nan adverse reaction or other physical harm to the participant or\n\nbeneficiary;\n\n4. Any treatment otherwise required under the protocol has\n\nprevented, will prevent, or is likely to prevent a participant or\n\nbeneficiary from achieving or maintaining reasonable and safe\n\nfunctional ability in performing occupational responsibilities or\n\nactivities of daily living; or\n\n5. The patient's disease state is classified as life\n\nthreatening.\n\nE. The process required by subsection C of this section shall:\n\n1. Provide the prescribing health care provider or beneficiary\n\nor designated third-party advocate an opportunity to present such\n\nprovider's clinical rationale and relevant medical information for\n\nthe group health plan or health insurance issuer to evaluate such\n\nrequest for exception;\n\n2. Clearly set forth all required information and the specific\n\ncriteria that will be used to determine whether an exception is\n\nwarranted, which may require disclosure of the medical history or\n\nother health records of the participant or beneficiary demonstrating\n\nthat the participant or beneficiary seeking an exception:\n\na. has tried other qualifying treatments without success,\n\nor\n\nb. has received the requested treatment for a clinically\nn and the specific\n\ncriteria that will be used to determine whether an exception is\n\nwarranted, which may require disclosure of the medical history or\n\nother health records of the participant or beneficiary demonstrating\n\nthat the participant or beneficiary seeking an exception:\n\na. has tried other qualifying treatments without success,\n\nor\n\nb. has received the requested treatment for a clinically\n\nappropriate amount of time to establish stability, in\n\nrelation to the condition being treated and guidelines\n\ngiven by the prescribing physician.\n\nOther clinical information that may be relevant to conducting\n\nthe exception review may require disclosure.\n\n3. Not require the submission of any information or supporting\n\ndocumentation beyond what is strictly necessary to determine whether\n\nany of the circumstances listed in subsection B of this section\n\nexist.\n\nF. The health benefit plan shall make information regarding the\n\nprocess required under subsection C of this section readily\n\navailable on the Internet website of the group health plan or health\n\ninsurance issuer. Such information shall include:\n\n1. The requirements for requesting an exception to a treatment\n\nstep therapy protocol pursuant to this section; and\n\n2. Any forms, supporting information, and contact information,\n\nas appropriate.\n\nG. The process required under paragraph 1 of subsection C of\n\nthis section shall provide for the disposition of requests received\n\nunder such paragraph in accordance with the following:\n\n1. Subject to paragraph 2 of this subsection, not later than\n\nseventy-two (72) hours after receiving an initial exception request,\n\nthe plan or issuer shall respond to the requesting prescriber with\n\neither a determination of exception eligibility or a request for\n\nadditional required information, strictly necessary to make a\n\ndetermination of whether the conditions specified in subsection D of\n\nthis section are met. The plan or issuer shall respond to the\n\nrequesting provider with a determination of exception eligibility no\n\nlater than seventy-two (72) hours after receipt of the additional\n\nrequired information; or\n\n2. In the case of a request under circumstances in which the\n\napplicable equipment step therapy protocol may seriously jeopardize\n\nthe life or health of the participant or beneficiary, the plan or\n\nissuer shall conduct a review of the request and respond to the\n\nrequesting prescriber with either a determination or exception\n\neligibility or a request for additional required information\n\nstrictly necessary to make a determination of whether the conditions\n\nspecified in subsection D of this section are met, in accordance\n\nwith the following:\n\na. if the plan or issuer can make a determination of\n\nexception eligibility without additional information,\n\nsuch determination shall be made on an expedited basis\n\nand no later than one (1) business day after receipt\n\nof such request, or\n\nb. if the plan or issuer requires additional information\n\nbefore making a determination of exception\n\neligibility, the plan or issuer shall respond to the\n\nrequesting provider with a request for such\n\ninformation within one (1) business day of the request\n\nfor a determination, and shall respond with a\n\ndetermination of exception eligibility as quickly as\n\nthe condition or disease requires and no later than\n\none (1) business day after receipt of the additional\n\nrequired information.\n\nH. This act shall apply with respect to any licensed provider\n\nin the State of Oklahoma that provides coverage of a treatment\n\npursuant to a policy that meets the definition of treatment step\n\ntherapy protocol in subsection B of this section, regardless of\n\nwhether such policy is described by such group health plan or health\n\ninsurance coverage as a step therapy protocol.","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":"6c50bd6e2ba390bce952157d9e4ea9f8b80a7417373a10913a9051507434e849","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-7321","next":"us-ok/okla.-stat.-tit.-63-63-79"},"notice":"GroundRules: Original legal text. Not legal advice."}