§ 414.772 — Limits on use of step therapy

Oregon § 414.772

• Jurisdiction: Oregon
• Vol.: 11
• Title 34: Human Services; Juvenile Code; Corrections
• Ch. 414: Medical Assistance

Text

(1) As used in this section, “step therapy” means a drug protocol in which the cost of a prescribed drug is reimbursed only if the patient has first tried a specified drug or series of drugs.
(2) A coordinated care organization that requires step therapy shall make easily accessible to any provider who is reimbursed by the organization, directly or through a risk-bearing entity, to provide health services to members of the organization, clear explanations of:
(a) The clinical criteria for each step therapy protocol;
(b) The procedure by which a provider may submit to the organization or risk-bearing entity, the provider’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 provider must submit to the organization or risk-bearing entity for the organization or entity to determine the appropriateness of step therapy for a specific patient.

Legislative History

Formerly 414.637