Okla. Stat. tit. 36, § 36-6570.50

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 provided,

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, reduced, 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:

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 hospital

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 facilities

available at the hospital or the independent,

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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;

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 Oklahoma Osteopathic Medicine

Act;

10. "Medically necessary" means drugs prescribed by a health

care provider that are:

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
that are:

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 practice of pharmacy;

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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

"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 making 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 review 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.