This text of Oregon § 743B.603 (Out-of-pocket maximums, deductibles, copayments, coinsurance and cost-sharing) is published on Counsel Stack Legal Research, covering Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.
(1)As used in this section:
(a)(A) “Generic equivalent” means a drug that meets applicable standards of strength, quality and purity according to the United States Pharmacopeia or other nationally recognized compendium and that, compared to a brand name drug:
(i)Has an identical amount of the same active chemical ingredients and the same dosage form; and
(ii)If administered in the same amounts, will provide comparable therapeutic effects.
(B)“Generic equivalent” does not include a drug that is listed by the United States Food and Drug Administration as having unresolved bioequivalence concerns according to the administration’s most recent publication of approved drug products with therapeutic equivalence evaluations.
(b)(A) “Health plan” means:
(i)An individual or group health benefit
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(1) As used in this section:
(a)(A) “Generic equivalent” means a drug that meets applicable standards of strength, quality and purity according to the United States Pharmacopeia or other nationally recognized compendium and that, compared to a brand name drug:
(i) Has an identical amount of the same active chemical ingredients and the same dosage form; and
(ii) If administered in the same amounts, will provide comparable therapeutic effects.
(B) “Generic equivalent” does not include a drug that is listed by the United States Food and Drug Administration as having unresolved bioequivalence concerns according to the administration’s most recent publication of approved drug products with therapeutic equivalence evaluations.
(b)(A) “Health plan” means:
(i) An individual or group health benefit plan, as defined in ORS 743B.005;
(ii) A plan providing coverage for a specific disease or condition only;
(iii) A medical services contract; or
(iv) Another similar certificate, policy, contract or arrangement or any endorsement or rider that covers all or a portion of the cost of an individual’s health care and that is subject to regulation by the Department of Consumer and Business Services.
(B) “Health plan” does not include coverages provided by:
(i) Medicare;
(ii) The state medical assistance program;
(iii) The federal government to federal employees;
(iv) TRICARE;
(v) Workers’ compensation;
(vi) Limited benefit coverage;
(vii) Accident only, credit, disability or long term care insurance; or
(viii) A health benefit plan offered by the Public Employees’ Benefit Board or the Oregon Educators Benefit Board through a commercial insurer, health care service contractor or a third party administrator.
(c) “High deductible health plan” means a health plan described in 26 U.S.C. 223.
(d) “Person” includes:
(A) An individual;
(B) A trust;
(C) An estate;
(D) A partnership;
(E) A corporation;
(F) An association;
(G) A joint stock company;
(H) An insurance company;
(I) A state;
(J) A political subdivision, instrumentality or municipal corporation of a state; or
(K) A nonprofit organization.
(e) “Pharmacy benefit manager” means a pharmacy benefit manager, as defined in ORS 735.530, that manages pharmacy benefits for a health plan.
(f) “Preventive services” has the meaning given that term in 42 U.S.C. 1395x.
(2) To the extent permitted by federal law, an insurer offering a health plan that provides pharmacy benefits and a pharmacy benefit manager shall include all amounts paid by an enrollee or paid by another person on behalf of an enrollee toward the cost of a covered prescription drug when calculating the enrollee’s contribution to an out-of-pocket maximum, deductible, copayment, coinsurance or other cost-sharing requirement applied to the drug if:
(a) The drug does not have a generic equivalent; or
(b) The drug has a generic equivalent and the enrollee has:
(A) Obtained prior authorization from the insurer or pharmacy benefit manager;
(B) Complied with a step therapy protocol; or
(C) Received approval from the insurer or pharmacy benefit manager through the insurer’s or the pharmacy benefit manager’s exceptions, appeal or review process.
(3) For high deductible health plans, the provisions of subsection (2) of this section apply only to preventive services until the enrollee has satisfied the minimum deductible under 26 U.S.C. 223(c)(2).