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SENATE FLOOR VERSION
April 4, 2023
ENGROSSED HOUSE
BILL NO. 1736 By: Townley, Miller, Conley,
and Davis of the House
and
Stanley of the Senate
An Act relating to step therapy protocol; defining
terms; requiring health benefit plans to implement a
new process; providing exceptions to step therapy
protocol; prescribing required processes; providing
for certain information or supporting documentation
not required for submission; providing standard for
determinations; requiring informatio n be readily
available on the health benefit pl an's website;
establishing disposition process fo r requests;
clarifying applicability of act; providing for
codification; and providing an effective date.
BE IT ENACTED BY THE PEOPLE OF THE STATE OF 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 numberin g, 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 noninvasive mechanical ventilation to treat
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chronic respiratory failure consequent to chronic obstructive
pulmonary disease (CRF -COPD), requiring a step therapy protocol.
B. "Treatment step therap y protocol" means a treatment
utilization management protocol or program under which a g roup
health plan or health insurance issuer offerin g group health
insurance coverage of respiratory care treatmen ts 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 benefic iary, 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.
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D. The circumstances requiring an e xception to a treatment step
therapy protocol, pursuant to a request und er subsection C of this
section, are any of the following:
1. Any treatments otherwise required under the protocol have
not been shown to be as effective 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 p articipant 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 reasona ble and safe
functional ability in performing occupati onal responsibilities or
activities of daily living; or
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5. The patient's disease state is classified as life
threatening.
E. The process required by subsection C of this section shall:
1. Provide the prescribing health care provider or beneficiary
or designated third-party advocate an opportunity to present such
provider's clinical rationale 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 info rmation and the specific
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 benefici ary 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 condition 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 supportin g
documentation beyond what is strictly necessary to d etermine whether
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any of the circumstances listed in subsection B of this section
exist.
F. The health benefit plan shall make information regarding the
process required under subsection C of this section readily
available on the Internet website of the gr oup 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 received
under such paragraph in accordance with the following:
1. Subject to paragraph 2 of this subsection, not lat er than
seventy-two (72) hours after receiving an initial exception request,
the plan or issuer shall respond to the requesting prescriber with
either a determination of exception eligibility or a reque st 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 respon d 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
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2. In the case of a request under circu mstances in which the
applicable equipment step therapy protocol may 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
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, in accordance
with the following:
a. if the plan or issuer can make a determination of
exception eligibility without additional information,
such determination shall be made on an expedited basis
and no later than one (1) business day after receipt
of such request, or
b. if the plan or issuer require s additional information
before making a determin ation of exception
eligibility, the plan or issuer shall resp ond to the
requesting provider with a request for such
information within one (1) business day 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 later than
one (1) business day after receipt of the additional
required information.
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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
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.
COMMITTEE REPORT BY: COMMITTEE ON RETIREMENT AND INSURANCE
April 4, 2023 - DO PASS