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ENGROSSED HOUSE
BILL NO. 1808 By: Newton, Deck, Pae, Miller,
Munson, Dempsey, and Lawson
of the House
and
Rader of the Senate
[ health insurance - Ensuring Transparency in
Prescription Drugs Prior Authorization Act -
disclosure and review of pr ior authorization for
prescription drugs - adverse determinations -
consultation - reviewing physicians - exception -
retrospective denial - continuity of care -
transmission of authorization – noncodification –
codification - effective date ]
BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
SECTION 1. NEW LAW A new section of law not to be
codified in the Oklahoma Statutes reads as follows:
This act shall be known and may be cited as the "Ensuring
Transparency in Prescrip tion Drugs Prior Authorization Act".
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SECTION 2. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.50 of Title 36, unless
there is created a duplication in numbering, reads as follows:
As used in this act:
1. "Adverse determination" means a determination by a health
carrier, pharmacy benefits manager (PBM), or its designee
utilization review entity that a prescription drug that is a covered
benefit has been reviewed and, based upon the information p rovided,
does not meet the health plan's or PBM's requirements for medical
necessity, appropriateness, health care setting, level of care, or
effectiveness, and the requested prescription drug or payment for
the prescription drug is therefore denied, reduc ed, or terminated as
defined by Section 6475.3 of Title 36 of the Oklahoma Statutes;
2. "Chronic condition" means a condition that lasts one (1)
year or more and requires ongoing medical attention or limits
activities of daily living or both;
3. "Clinical criteria" means the written policies, written
screening procedures, determination rules, determination abstracts,
clinical protocols, practice guidelines, medical protocols, and any
other criteria or rationale used by the utilization review entity to
determine the necessity and appropriateness of prescription drugs;
4. "Emergency health care services", with respect to an
emergency medical condition as defined in 42 U.S.C.A., Section
300gg-111, means:
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a. a medical screening examination, as required under
Section 1867 of the Social Security Act, 42 U.S.C.,
Section 1395dd, or as would be required under such
section if such section applied to an independent,
freestanding emergency department, that is within the
capability of the emergency department of a hosp ital
or of an independent, freestanding emergency
department, as applicable, including ancillary
services routinely available to the emergency
department to evaluate such emergency medical
condition, and
b. within the capabilities of the staff and faciliti es
available at the hospital or the independent,
freestanding emergency department, as applicable, such
further medical examination and treatment as are
required under Section 1395dd of the Social Security
Act, or as would be required under such section if
such section applied to an independent, freestanding
emergency department, to stabilize the patient,
regardless of the department of the hospital in which
such further examination or treatment is furnished, as
defined by 42 U.S.C.A., Section 300gg -111;
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5. "Emergency Medical Treatment and Active Labor Act" or
"EMTALA" means Section 1867 of the Social Security Act and
associated regulations;
6. "Enrollee" means an individual who is enrolled in a health
care plan, including covered dependents, as defined by Section
6592.1 of Title 36 of the Oklahoma Statutes;
7. "Health care provider" means any person or other entity who
is licensed pursuant to the provisions of Title 59 or Title 63 of
the Oklahoma Statutes, or pursuant to the definition in Section 1 -
1708.1C of Title 63 of the Oklahoma Statutes;
8. "Health plan" means a health benefit plan as defined by
Section 6060.4 of Title 36 of the Oklahoma Statutes;
9. "Licensed mental health professional" means:
a. a psychiatrist who is a diplomate of the American
Board of Psychiatry and Neurology,
b. a psychiatrist who is a diplomate of the American
Osteopathic Board of Neurology and Psychiatry, or
c. a physician licensed pursuant to the Oklahoma
Allopathic Medical and Surgical Licensure and
Supervision Act or the O klahoma Osteopathic Medicine
Act;
10. "Medically necessary" means drugs prescribed by a health
care provider that are:
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a. appropriate for the symptoms and diagnosis or
treatment of the enrollee's condition, illness,
disease, or injury,
b. in accordance with standards of good medical practice,
c. not primarily for the convenience of the enrollee or
the enrollee's health care provider, and
d. the most appropriate supply and prescription drug that
can safely be provided to the enrollee as defined by
Section 6592 of Title 36 of the Oklahoma Statutes;
11. "Notice" means communication delivered either
electronically or through the United States Postal Service or common
carrier;
12. "Pharmacist" means a person licensed by the Board of
Pharmacy to engage in the p ractice of pharmacy;
13. "PBM" means a pharmacy benefits manager as defined by
Section 357 of Title 59 of the Oklahoma Statutes;
14. "Physician" means an allopathic or osteopathic physician
licensed by the State of Oklahoma or another state to practice
medicine;
15. "Prior authorization" means the process by which
utilization review entities determine the medical necessity and
medical appropriateness of otherwise covered prescription drug prior
to the dispensing of such prescription drug. The term shall include
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"authorization", "pre -certification", and any other term that would
be a reliable determination by a health benefit plan;
16. "Urgent prescription drug" means a prescription drug with
respect to which the application of the time periods for makin g an
urgent care determination, which, in the opinion of a physician with
knowledge of the enrollee's medical condition:
a. could seriously jeopardize the life or health of the
enrollee or the ability of the enrollee to regain
maximum function, or
b. in the opinion of a physician with knowledge of the
claimant's medical condition, would subject the
enrollee to severe pain that cannot be adequately
managed without the care or treatment that is the
subject of the utilization review; and
17. "Utilization revi ew entity" means an individual or entity
that performs prior authorization for a health benefit plan as
defined by Section 6060.4 of Title 36 of the Oklahoma Statutes.
SECTION 3. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.51 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A utilization review entity shall make any current prescription
drug prior authorization requirements and restrictions, including
written clinical criteria, readily accessible on its website to
enrollees and health care providers. Prior authorization
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requirements shall be described in detail but also in easily
understandable language.
Any health plan shall make any current prescription drug plan
formulary readily accessible on its website to enrollees and health
care providers.
All health benefit plans shall submit a secured webpage link for
the plan's formulary, to the Insurance Commissioner, on or before
October 1 of each year. The Commis sioner shall issue guidance and
standardized reporting requirements to ensure compliance with the
provisions of this section. Any confidential or trade secret
information shall be redacted prior to submission to the
Commissioner. No later than December 3 1, 2025, and by December 31
of each year thereafter, the Commissioner shall make available to
the public the reports submitted by insurers, as required by this
section.
If a utilization review entity intends either to implement a new
prior authorization re quirement or restriction, or amend an existing
requirement or restriction, the utilization review entity shall
ensure that the new or amended requirement or restriction is not
implemented unless the utilization review entity's website has been
updated to reflect the new or amended requirement or restriction.
If a utilization review entity intends either to implement a new
prior authorization requirement or restriction, or amend an existing
requirement or restriction, the utilization review entity shall
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provide contracted health care providers credentialed to prescribe
the drug, or enrollees who have a chronic condition and are already
receiving the prescription drug which the prior authorization
changes will impact, notice of the new or amended requirement o r
restriction no less than sixty (60) days before the requirement or
restriction is implemented.
Provided the provisions of this section do not violate any
applicable law, regulation, or the Oklahoma Medicaid State Plan.
SECTION 4. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.52 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A utilization review entity shall ensure that all adverse
determinations include alte rnative prescription drugs covered by the
health plan's formulary and are made by a physician, pharmacist, or
licensed mental health professional. The physician, pharmacist, or
licensed mental health professional shall:
1. Possess a current and valid non restricted license in any
United States jurisdiction;
2. Have the appropriate training, knowledge, or expertise to
apply appropriate clinical guidelines to the health care service
being requested; and
3. Make the adverse determination under the clinical direction
provided by the committee or board responsible for developing
policies for drug use, evaluating clinical appropriateness, and
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ensuring effective drug use when reviewing prescription drug prior
authorizations to enrollees of Oklahoma. All such me dical directors
shall be physicians licensed in any United States jurisdiction.
SECTION 5. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.53 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A utilization review entity shall ensure that all appeals are
reviewed by a physician, pharmacist, or licensed mental health
professional. The physician, pharmacist, or licensed mental health
professional shall:
1. Possess a current and valid unrestricted license in any
United States jurisdiction;
2. Be of the same or similar specialty as a physician,
pharmacist, or licensed mental health professional who typically
manages the medical condition or disease, which means that t he
physician either maintains board certification for the same or
similar specialty as the medical condition in question or whose
training and experience:
a. includes treating the condition,
b. includes treating complications that may result from
the service or procedure, and
c. is sufficient for the physician, pharmacist, or
licensed mental health professional to determine if
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the service or procedure is medically necessary or
clinically appropriate,
except for appeals coming from a licensed mental health
professional, which may be conducted by another licensed mental
health professional as opposed to a physician, or for appeals coming
from a pharmacist, which may be conducted by another licensed
pharmacist as opposed to a physician;
3. Not have been direct ly involved in making the adverse
determination;
4. Not have any financial interest in the outcome of the
appeal; and
5. Consider all known clinical aspects of the health care
service under review, including, but not limited to, a review of
those medical records which are pertinent and relevant to the active
condition provided to the utilization review entity by the
enrollee's health care provider, or a health care facility, and any
pertinent medical literature provided to the utilization review
entity by the health care provider.
SECTION 6. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.54 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. If a utilization re view entity requires prior authorization
of a prescription drug, the utilization review entity shall make a
prior authorization or adverse determination and notify the enrollee
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and the enrollee's health care provider of the prior authorization
or adverse determination in accordance with the time frames set
forth below:
1. For purposes of approving prior authorization for urgent
prescription drugs, within twenty -four (24) hours of obtaining all
necessary information to make the prior authorization or advers e
determination; or
2. For purposes of approving prior authorization for nonurgent
prescription drugs, within four (4) business days of obtaining all
necessary information to make the prior authorization or adverse
determination.
For purposes of this sect ion, "necessary information" includes,
but is not limited to, the results of any face -to-face clinical
evaluation or second opinion that may be required.
B. For those health care providers that submit all necessary
information through the utilization revi ew entity's authorized prior
authorization system, prescription drugs are deemed authorized if a
utilization review entity fails to comply with the deadlines set
forth in this section.
C. In the notification to the health care provider that a prior
authorization has been approved, the utilization review entity shall
include in such notification the duration of the prior authorization
or the date by which the prior authorization will expire.
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SECTION 7. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.55 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A utilization review entity shall not require prior
authorization for prescription drugs administered as a part of t he
provision of emergency health care services.
SECTION 8. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.56 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. If a prior authorization is required for a prescription drug
for the treatment of a chronic condition of an enrollee, and the
enrollee remains on the same health plan, then the prior
authorization shall remain valid for three (3) years from the date
the health care provider receives the prior authorization approval,
unless clinical criteria changes, the enrollee's health plan removes
the generic prescription drug from the formulary, or moves the
prescription drug to a less preferred tier status on its for mulary.
B. This section shall not apply to prior authorizations
approved for:
1. A prescription drug that is an opioid or is a controlled
substance that is prohibited from being dispensed without a
prescription under the Federal Food, Drug, and Cosmetic Act, 21
U.S.C., Section 301 et seq., as amended; or
2. A prescription drug for the treatment of weight loss.
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C. Provided the provisions of this section do not violate any
applicable law, regulation, or the Oklahoma Medicaid State Plan.
SECTION 9. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.57 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. On receipt of information documenting a prior authorization
from the enrollee or from the enrollee's health care provider, a
utilization review entity shall honor a prior authorization granted
to an enrollee from a previous utilization review entity for at
least the initial sixty (60) days of an enrollee's coverage und er a
new health plan.
B. During the time period described in subsection A of this
section, a utilization review entity may perform its own review to
grant a prior authorization or make an adverse determination.
C. A utilization review entity shall contin ue to honor a prior
authorization it has granted to an enrollee when the enrollee
changes products under the same health insurance company for the
initial sixty (60) days of an enrollee's coverage under the new
product unless the service is no longer a cov ered service under the
new product.
D. During the time period described in subsection C of this
section, a utilization review entity may simultaneously perform a
review to grant a prior authorization or to make an adverse
determination.
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E. Provided the provisions of this section do not violate any
applicable law, regulation, or the Oklahoma Medicaid State Plan.
SECTION 10. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.58 of Title 36, unless
there is created a duplication in numbering, reads as follows:
A. 1. The Insurance Commissioner may, if the Commissioner
finds that any person or organization has violated the provisions of
this act, impose a penalty of not more than Five Thousand Dollars
($5,000.00) for each such violation. Such penalties may be in
addition to any other penalty provided by law.
2. No penalty shall be imposed except upon written order of the
Commissioner or the appointed independent hearing examiner, stating
the findings of the Commissioner or the appointed independent
hearing examiner after the notice and opportunity for a hearing in
accordance with Article II of the Administrative Procedures Act.
B. 1. The Attorney General may, if the Attorney General finds
that a pharmacy benefits manager has violated the provisions of this
act, impose a penalty of not more than Five Thousand Dollars
($5,000.00) for each such violation. Such penalties may be in
addition to any other penalty provided by law.
2. No penalty shall be impo sed except upon written order of the
Attorney General or the appointed independent hearing examiner,
stating the findings of the Attorney General or the appointed
independent hearing examiner after the notice and opportunity for a
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hearing in accordance wit h Article II of the Administrative
Procedures Act.
SECTION 11. NEW LAW A new section of law to be codified
in the Oklahoma Statutes as Section 6570.59 of Title 36, unless
there is created a duplication in numbering, reads as follows:
This act shall apply to the Oklahoma Medicaid State Plan.
SECTION 12. This act shall become effective November 1, 2025.
Passed the House of Representatives the 24th day of March, 2025.
Presiding Officer of the House
of Representatives
Passed the Senate the _____ day of __________, 2025.
Presiding Officer of the Senate