(a) "Health care coverage plan" includes:

(A) A health benefit plan, as defined in ORS 743B.005;

(B) An insurance policy or certificate covering the cost of prescription drugs, hospital expenses, health care services and medical expenses, equipment and supplies;

(C) A medical services contract, as defined in ORS 743B.001;

(D) A multiple employer welfare arrangement, as defined in ORS 750.301;

(E) A contract or agreement with a health care service contractor, as defined in ORS 750.005, or a preferred provider organization;

(F) A pharmacy benefit manager, as defined in ORS 735.530, or other third party administrator that pays prescription drug claims; and

(G) An accident insurance policy or any other insurance contract providing reimbursement for the cost of prescription drugs, hospital expenses, health care services and medical expenses, equipment and supplies.

(b) "Step therapy" means a drug protocol in which a health care coverage plan will reimburse the cost of a prescribed drug only if the patient has first tried a specified drug or series of drugs.

(2) A health care coverage plan that requires step therapy shall make easily accessible to prescribing practitioners, clear explanations of:

(a) The clinical criteria for each step therapy protocol;

(b) The procedure by which a practitioner may submit to the plan the practitioner’s medical rationale for determining that a particular step therapy protocol is not appropriate for a particular patient based on the patient’s medical condition and history; and

(c) The documentation, if any, that a practitioner must submit to the plan for the plan to determine the appropriateness of step therapy for a specific patient. [2014 c.55 §4]

Note: 743B.602 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.