Req. No. 7841 Page 1 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
STATE OF OKLAHOMA
1st Session of the 59th Legislature (2023)
COMMITTEE SUBSTITUTE
FOR
HOUSE BILL NO. 1736 By: Townley
COMMITTEE SUBSTITUTE
An Act relating to step therapy protocol; defining
terms; requiring health benefit plans to implement a
new process; providing exceptions to step therapy
protocol; requiring information be readily available
on the health benefit plans website; establishing
disposition process fo r requests; clarifying whom
this act applies to; providing for codification; and
providing for an effective date .
BE IT ENACTED BY THE PEOPLE OF THE STATE O F OKLAHOMA:
SECTION 1. NEW LAW A new section of law to be codifie d
in the Oklahoma Statutes as Section 7330 of Title 63, unless there
is created a duplication in numbering, reads as follows:
A. "Health benefit plan" means a plan as defined pursuant to
Section 6060.4 of Title 3 6 of the Oklahoma Statutes , that provides
coverage for invasive or non-invasive mechanical ventilation to
treat chronic respiratory failure consequent to chronic obstructive
pulmonary disease (CRF -COPD), requiring a step therapy protocol.
B. "Treatment step therapy protocol " means a treatment
utilization management protocol or program under which a g roup
Req. No. 7841 Page 2 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
health plan or health insurance issuer offering group health
insurance coverage of respiratory care treatments requires a
participant or beneficiary to tr y an alternative, plan -preferred,
treatment and fail on this treatment before the plan or health
insurance issuer approves coverage for the non -preferred therapy
prescribed by the beneficiaries medical provider .
C. A health benefit plan shall:
1. Implement a clear and transparent process for a pa rticipant
or beneficiary, or the prescribing health ca re provider on behalf of
the participant or beneficiary , with CRF-COPD to request an
exception to such a step therapy protocol, pursuant to subsection B
of this section; and
2. Where the participant or beneficiary or prescribing health
care provider's request for an exception to the treatment step
therapy protocols satisfies the criteria and requirements of
subsection D of this section, cover the requested treatment in
accordance with the terms established by the health plan or coverage
for patient cost-sharing rates or amounts at the time of the
participant's or beneficiary's enrollment in the health plan or
health insurance coverage.
D. The circumstances requiring an exception to a treatment step
therapy protocol, pursuant to a request und er subsection C of this
section, are any of the following:
Req. No. 7841 Page 3 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1. Any treatments otherwise required under the protocol, have
not been shown to be as eff ective as other available options in the
treatment of the disease or condition or the participant or
beneficiary, when prescribed consistent with clinical indications,
clinical guidelines, or other peer-reviewed evidence;
2. Delay of proven effective treatment would lead to severe or
irreversible consequences, and the tre atment initially required
under the protocol is reasonably expected to be less effective
based upon the documented physical or mental characteristics of the
participant or beneficiary and the known characteristics of such
treatment;
3. Any treatments otherwise required under the protocol are
contraindicated for the participant or beneficiary or have caused,
or are likely to cause, based on clinical, peer -reviewed evidence,
an adverse reaction or other physical harm to the participant or
beneficiary;
4. Any treatment otherwise required under the prot ocol has
prevented, will prevent, or is likely to prevent a participant or
beneficiary from achieving or maintaining reasonable and safe
functional ability in performing occupational responsibilities or
activities of daily living; or
5. The patient's disease state is classified as life
threatening.
E. The process required by subsection C of this section shall:
Req. No. 7841 Page 4 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
1. Provide the prescribing health care provider or beneficiary
or designated third-party advocate an opportunity to present such
provider's clinical rational and relevant medical information for
the group health plan or health insurance issuer to evaluate such
request for exception;
2. Clearly set forth all required information and the sp ecific
criteria that will be used to determine whether an exception is
warranted, which may require disclosure of the medical history or
other health records of the participant or beneficiary demonstrating
that the participant or beneficiary seeking an exception :
a. has tried other qualifying treatments without success,
or
b. has received the requested treatment for a clinically
appropriate amount of time t o establish stability, in
relation to the condi tion being treated and guidelines
given by the prescribing physician .
Other clinical information that may be relevant to conducting
the exception review may require disclosure.
3. Not require the submission of any information or supporting
documentation beyond what is strictly necessary to determine whether
any of the circumstances listed in subsection B of this section
exist.
F. The health benefit plan shall make information reg arding the
process required under subsection C of this section readily
Req. No. 7841 Page 5 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
available on the internet website of the group health plan or health
insurance issuer. Such information shall include:
1. The requirements for requesting an exception to a treatment
step therapy protocol pursuant to this section; and
2. Any forms, supporting information, and contact information,
as appropriate.
G. The process required under paragraph 1 of subsection C of
this section, shall provide for the disposition of requests re ceived
under such paragraph in accordance with the following:
1. Subject to paragraph 2 of this subsection, not later than
seventy-two (72) hours after receiving an initial exception request,
the plan or issuer shall respond to the requesting prescriber w ith
either a determination of exception eligibility or a request for
additional required information , strictly necessary to make a
determination of whether the conditions specified in subsection D of
this section are met. The plan or issuer shall respond to the
requesting provider with a determination of exception eligibility no
later than seventy-two (72) hours after receipt of the additional
required information; or
2. In the case of a request under circu mstances in which the
applicable equipment step therapy protocol m ay seriously jeopardize
the life or health of the participant or beneficiary, the plan or
issuer shall conduct a review of the reque st and respond to the
requesting prescriber with either a determination or exception
Req. No. 7841 Page 6 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
eligibility or a request for additiona l required information
strictly necessary to make a determination of whether the conditions
specified in subsection D of this section are met, in accordance
with the following:
a. if the plan or issuer can make a determination of
exception eligibility w ithout additional information,
such determination shall be made on an expedited
basis, and no later than twenty -four (24) hours after
receipt of such request, or
b. if the plan or issuer require s additional information
before making a determination of exception
eligibility, the plan or issuer shall resp ond to the
requesting provider with a request for such
information within twenty -four (24) hours of the
request for a determination, and shall res pond with a
determination of exception eligibility as quickly as
the condition or disease requires, and no lat er than
twenty-four (24) hours after receipt of the additional
required information.
H. This act shall apply with respect to any licen sed provider
in the state of Oklahoma that provides coverage of a treatment
pursuant to a policy that meets the definitio n of treatment step
therapy protocol in subsection B of this section, regardless of
Req. No. 7841 Page 7 1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
whether such policy is described by such group he alth plan or health
insurance coverage as a step therapy protocol.
SECTION 2. This act shall become effective November 1, 2023.
59-1-7841 MJ 03/01/23