Oklahoma Administrative Code
Title 317 - Oklahoma Health Care Authority
Chapter 30 - Medical Providers-Fee for Service
Subchapter 5 - Individual Providers and Specialties
Part 5 - PHARMACIES
Section 317:30-5-77.4 - Step therapy exception process
Universal Citation: OK Admin Code 317:30-5-77.4
Current through Vol. 42, No. 1, September 16, 2024
(a) Definitions.
(1)
"Exigent
circumstances" means circumstances in which a delay in receiving a
prescription drug will jeopardize the member's life or health or ability to
attain, maintain, or regain maximum function.
(2)
"Step therapy" or
"step therapy protocol" means a protocol or program that
establishes a specific sequence in which prescription drugs for a specified
medical condition that are medically appropriate for a particular patient are
covered by Medicaid. Step therapy protocols are based upon the recommendation
of the Drug Utilization Review (DUR) Board, as approved by the Oklahoma Health
Care Authority (OHCA) Board.
(3) A
"step therapy exception" means the process by which a step therapy
protocol is overridden in favor of immediate coverage of a SoonerCare
provider's selected prescription drug.
(b) Process. The step therapy exception process shall be initiated by a SoonerCare provider on behalf of a SoonerCare member. An exception can be requested following a denial of a prior authorization request for the specified prescription drug(s), or can be requested at the outset. In either case, the provider shall:
(1) Submit the exception request using the
step therapy exception request form, which is available on the OHCA website
and/or provider portal; and
(2)
Submit with the step therapy exception request form, documentation or other
information adequate to support the medical necessity for overriding the
otherwise-applicable step therapy protocol for the particular prescription
drug.
(3) A properly-supported
step therapy exception request will be granted if it demonstrates that any of
the following circumstances exists:
(A) The
required prescription drug is contraindicated or will likely cause an adverse
reaction or physical or mental harm to the patient;
(B) The required prescription drug is
expected to be ineffective based on the known clinical characteristics of the
patient and the known characteristics of the prescription drug;
(C) The patient has tried the required
prescription drug while under the patient's current or a previous health
insurance plan and such prescription drug was discontinued due to lack of
efficacy or effectiveness, diminished effect, or an adverse event;
(D) The required prescription drug is not in
the best interest of the patient, based on medical necessity; or
(E) The patient is stable on a prescription
drug selected by the patient's healthcare provider for the medical condition
under consideration while on the patient's current or a previous health
insurance plan.
(4) The
OHCA or its contractor or designee may request additional information that is
reasonably necessary to determine whether a step therapy exception request
should be granted, as provided by Oklahoma law.
(c) Notification.
(1) The OHCA or its contractor or designee
shall respond to any step therapy exception request within seventy-two (72)
hours of the submission of a completed and properly-supported request. For
exigent circumstances, the OHCA shall respond to the exception request within
twenty-four (24) hours of receipt. Provided, however, that if the timeframe for
response ends on a weekend, or on any other day the OHCA is closed or closes
early, including, but not limited to, legal holidays as defined by 25 O.S.
§ 82.1, the timeframe for response shall run until the close of the next
full business day. Any exception request not responded to within this timeframe
shall be deemed granted.
(2) The
OHCA shall respond to a request for a step therapy exception by:
(A) Notifying the provider that the request
is approved;
(B) Notifying the
provider that the request is not approved based on medical necessity;
(C) Notifying the provider that
the medical necessity of the requested exception cannot be approved or denied
as a result of missing or incomplete documentation or information necessary to
approve or disapprove the request;
(D) Notifying the provider that the member is
no longer eligible for coverage; or
(E) Notifying the provider that the step
therapy exemption request cannot be processed because it was not properly
submitted using the required form.
(3) The rejection of a step therapy exception
request based upon missing or incomplete documentation or other information, or
because it was not properly submitted using the required form is not a denial,
and shall not be subject to further appeal. It must, instead, be resubmitted as
a new request for exception pursuant to this rule before it will be considered
for approval.
(d) Appeal. If a step therapy exception request is denied, an appeal may be initiated by the member within thirty (30) days of the denial pursuant to Oklahoma Administrative Code (OAC) 317:2-1-18.
Disclaimer: These regulations may not be the most recent version. Oklahoma may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
