Oregon Revised Statutes
As used in this section and ORS 743.008, 743.029, 743.035, 743A.112, 743A.190, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.220, 743B.225, 743B.227, 743B.250, 743B.252, 743B.253, 743B.254, 743B.255, 743B.256, 743B.257, 743B.258, 743B.310, 743B.400, 743B.403, 743B.405, 743B.420, 743B.422, 743B.423, 743B.424, 743B.425, 743B.430, 743B.445, 743B.450, 7…
The purposes of ORS 743.004, 743.022, 743.535, 743B.003 to 743B.127 and 743B.800 are: To promote the availability of health insurance coverage to groups regardless of their enrollees’ health status or claims experience; To prevent abusive rating practices; To require disclosure of rating practices to purchasers of small employer and individual health bene…
For purposes of ORS 743.004, 743.007, 743.022, 743.416, 743.417, 743.535, 743A.101, 743B.003 to 743B.127, 743B.109, 743B.128, 743B.250 and 743B.323: “Actuarial certification” means a written statement by a member of the American Academy of Actuaries or other individual acceptable to the Director of the Department of Consumer and Business Services that a car…
If an affiliated group of employers is treated as a single employer under section 414(b), (c), (m) or (o) of the Internal Revenue Code of 1986, a carrier may issue a single group health benefit plan to the affiliated group on the basis of the number of employees in the affiliated group if the group requests such coverage. Subsequent to the issuance of a hea…
Except as provided in subsection (2) of this section, every health benefit plan shall be subject to the provisions of ORS 743B.010 to 743B.013, if the plan provides health benefits covering one or more employees of a small employer and if any one of the following conditions is met: Any portion of the premium or benefits is paid by a small employer or any em…
As a condition of transacting business in the small employer health insurance market in this state, a carrier shall offer small employers all of the carrier’s health benefit plans, approved by the Department of Consumer and Business Services for use in the small employer market, for which the small employer is eligible. A carrier shall issue to a small empl…
A health benefit plan issued to a small employer: Other than a grandfathered health plan, must cover essential health benefits consistent with 42 U.S.C. 300gg-11. May require an affiliation period that does not exceed two months for an enrollee or 90 days for a late enrollee. May not apply a preexisting condition exclusion to any enrollee. Late enrollees…
The Department of Consumer and Business Services shall adopt by rule a method for determining whether: An employee is an eligible employee as defined in ORS 743B.005; and An employer is a small employer as defined in ORS 743B.005. The method adopted by the department under subsection (1) of this section must be consistent with corresponding federal requir…
In order to ensure the broadest availability of small employer and individual health benefit plans, the Department of Consumer and Business Services may approve market conduct and other requirements for carriers and insurance producers, including: Registration by each carrier with the department of the carrier’s intention to offer group health benefit plans…
All carriers that offer individual or group health benefit plans shall provide certifications and disclosure of coverage in accordance with 42 U.S.C. 300gg(e) and 300gg-43 as amended and in effect on July 1, 1997.
A carrier may not: Require an applicant to provide health-related information as a precondition for the issuance of an individual health benefit plan policy; or Deny coverage under an individual health benefit plan policy based on health-related information provided by the applicant. A carrier may require an enrollee in a health benefit plan to complete t…
Except in the case of a late enrollee and as otherwise provided in this section, a carrier offering a group health benefit plan to a group of two or more prospective certificate holders shall not decline to offer coverage to any eligible prospective enrollee and shall not impose different terms or conditions on the coverage, premiums or contributions of any …
The following requirements apply to all group health benefit plans other than small employer health benefit plans covering two or more certificate holders: A carrier offering a group health benefit plan may not decline to offer coverage to any eligible prospective enrollee and may not impose different terms or conditions on the coverage, premiums or contrib…
An insurer offering a short term health insurance policy in this state shall include in any policy document, application materials or advertisements related to the policy a notice informing an insured or prospective insured under the policy that: The policy is not subject to certain federal requirements for health insurance, including requirements in the Pa…
The Department of Consumer and Business Services may adopt rules incorporating, implementing and administering the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191), the Patient Protection and Affordable Care Act (P.L. 111-148) as amended by the Health Care and Education Reconciliation Act (P.L. 111-152) and federal regulations that …
With respect to coverage under an individual health benefit plan, a carrier may not impose a preexisting condition exclusion or an individual coverage waiting period. With respect to individual coverage under a grandfathered health plan, a carrier: May impose an exclusion period for specified covered services applicable to all individuals enrolling for the…
Each carrier shall actively market all individual health benefit plans sold by the carrier that are not grandfathered health plans. Except as provided in subsection (3) of this section, no carrier or insurance producer shall, directly or indirectly, discourage an individual from filing an application for coverage because of the health status, claims experie…
The Director of the Department of Consumer and Business Services shall adopt all rules necessary for the implementation and administration of ORS 743.022, 743B.125 and 743B.126.
Notwithstanding ORS 743B.012, 743B.013 and 743B.105, a carrier is not required to actively market: A health benefit plan sold only to a bona fide association, to groups that are not members of the bona fide association; A grandfathered health plan, to a group or individual who is not eligible for coverage under the plan; A group health benefit plan, to a …
As used in this section, “procedural requirements” means the processes that the Department of Consumer and Business Services will use to obtain public input such as public hearings, rule comment periods and the electronic distribution of information by the department. The department shall adopt rules establishing standards for shortening the period of prohi…
In each individual or small group market, in which a carrier offers a health benefit plan through or outside of the health insurance exchange described in ORS 741.310, the carrier must offer to residents of this state bronze and silver plans meeting the requirements of subsection (2) of this section and, if offered through the health insurance exchange, cert…
The Department of Consumer and Business Services shall enforce insurer compliance with the federal Newborns’ and Mothers’ Health Protection Act of 1996.
The Director of the Department of Consumer and Business Services shall appoint a Health Care Consumer Protection Advisory Committee with fair representation of health care consumers, providers and insurers. The committee shall advise the director regarding the implementation of ORS 743.008, 743A.012, 743B.001, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204…
Each insurer offering managed health insurance in this state shall: Have a quality assessment program that enables the insurer to evaluate, maintain and improve the quality of health services provided to enrollees. The program shall include data gathering that allows the plan to measure progress on specific quality improvement goals chosen by the insurer. …
An insurer offering managed health insurance or preferred provider organization insurance in this state shall: File an annual summary with the Department of Consumer and Business Services that reports on the scope and adequacy of the insurer’s network and the insurer’s ongoing monitoring to ensure that all covered services are reasonably accessible to enrol…
All insurers offering managed health insurance in this state shall include in contracts with providers a provision requiring that in the event the insurer fails to pay for health care services covered by the health benefit plan, the provider shall not bill or otherwise attempt to collect from enrollees for amounts owed by insurers, and enrollees shall not be…
All insurers offering a health benefit plan in this state that requires an enrollee to designate a participating primary care physician shall: Permit the enrollee to change participating primary care physicians at will, except that the enrollee may be restricted to making changes no more frequently than two times in any 12-month period and may be limited to…
As used in this section, “primary care provider” means an individual, clinic or team of health care providers licensed or certified in this state to provide outpatient, nonspecialty medical services or the coordination of health care for the purpose of: Promoting or maintaining mental and physical health and wellness; and Diagnosis, treatment or management…
As used in this section, “women’s health care provider” means an obstetrician or gynecologist, physician associate specializing in women’s health, advanced registered nurse practitioner specialist in women’s health, naturopathic physician specializing in women’s health or certified nurse midwife, practicing within the applicable lawful scope of practice. Ev…
As used in this section, “continuity of care” means the feature of a health benefit plan under which an enrollee who is receiving care from an individual provider is entitled to continue with care with the individual provider for a limited period of time after the medical services contract terminates. An insurer offering managed health insurance or preferre…
If an insurer offers a health benefit plan that requires, as a condition of coverage for specialty care services, a referral by a physician who is authorized under the plan or under the medical services contract between the physician and the insurer to refer an enrollee to specialty care services, the insurer must include the requirements of this section in …
All insurers offering a health benefit plan in this state shall: Provide to all enrollees directly or in the case of a group policy to the employer or other policyholder for distribution to enrollees, to all applicants, and to prospective applicants upon request, the following information: The insurer’s written policy on the rights of enrollees, including …
An insurer offering health benefit plans in this state shall have an external review program that meets the requirements of this section and ORS 743B.255 and rules adopted by the Director of the Department of Consumer and Business Services to carry out the provisions of this section and ORS 743B.250 and 743B.255. Each insurer shall provide the external revie…
The Director of the Department of Consumer and Business Services shall contract with independent review organizations as provided in this section for the purpose of providing external review under ORS 743B.252. Contracts shall be let with independent review organizations on a biennial basis. A contract may be renewed if both parties agree. The director shal…
An insurer offering a health benefit plan shall include in the plan the following statements, in boldfaced type or otherwise emphasized: A statement of the right of an enrollee to apply for external review by an independent review organization; A statement that an enrollee applying for external review by an independent review organization may be required t…
An enrollee shall apply in writing for external review of an adverse benefit determination by the insurer of a health benefit plan not later than the 180th day after receipt of the insurer’s final written decision following its grievance and internal appeal process under ORS 743B.250. An enrollee is eligible for external review only if the enrollee has exha…
An independent review organization shall perform the following duties when appointed under ORS 743B.252 to review a dispute under a health benefit plan between an insurer and an enrollee: Decide whether the dispute pertains to an adverse benefit determination and notify the enrollee and insurer in writing of the decision. If the decision is against the enro…
An insurer shall comply in a timely manner with a decision of an independent review organization under ORS 743B.256 that reverses, in whole or in part, an adverse benefit determination. If an insurer fails to comply with the decision, the Director of the Department of Consumer and Business Services may impose on the insurer a civil penalty of not more than $…
An enrollee who is the subject of a decision of an independent review organization has a private right of action against the insurer for damages arising from an adverse benefit determination by the insurer that is subject to external review if the insurer fails to comply with the decision. The Legislative Assembly intends that there is no private right of a…
As used in this section: “Adverse benefit determination” means a denial, reduction, termination of or failure to provide or pay, in whole or in part, for a benefit, including: A denial, reduction, termination of or failure to provide or pay for a benefit that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a po…
As used in ORS 743B.275 to 743B.285: “In-network” means performed by a provider or provider group that has directly contracted with the insurer. “Out-of-network” means performed by a provider or provider group that has not contracted or has indirectly contracted with the insurer. Note: 743B.275 to 743B.285 were enacted into law by the Legislative Assembly…
An insurer offering a health benefit plan as defined in ORS 743B.005 shall credit any amount an enrollee pays directly to a health care provider to the enrollee’s deductible and annual out-of-pocket expenses if: The health care item or service is medically necessary and covered under the enrollee’s health benefit plan; The enrollee does not submit the clai…
An insurer offering a health benefit plan as defined in ORS 743B.005 must establish a procedure for providing to an enrollee in the plan a reasonable estimate of an enrollee’s costs for an in-network procedure or service covered by the enrollee’s health benefit plan, in advance of the procedure or service, when an enrollee or an enrollee’s authorized represe…
An insurer offering a health benefit plan as defined in ORS 743B.005 must establish a procedure for providing to an enrollee in the plan a reasonable estimate of the enrollee’s costs for an out-of-network procedure or service covered by the enrollee’s health benefit plan, including the difference between the insurer’s allowable charge and the billed charge f…
An insurer offering a health benefit plan as defined in ORS 743B.005 must submit to the Director of the Department of Consumer and Business Services: Upon request by the director, the methodology used to determine the insurer’s allowable charges for out-of-network procedures and services or, if the insurer uses a third party to determine the charges, the me…
The Director of the Department of Consumer and Business Services may waive the requirements of ORS 743B.281 or 743B.282 to allow an insurer to use an alternative disclosure mechanism, provided that the mechanism enables enrollees to access information substantially similar to or more extensive than the information disclosed in ORS 743B.281 or 743B.282. Note…
The Director of the Department of Consumer and Business Services shall adopt rules necessary to carry out the purposes of ORS 743B.275 to 743B.285. Note: See note under 743B.275.
As used in this section: “Emergency services” has the meaning given that term in ORS 743A.012. “Enrollee” means: An individual who is enrolled in a health benefit plan or a covered dependent or beneficiary of the individual; or A subscriber to a health care service contract or a covered dependent or beneficiary of the subscriber. “Health benefit plan” h…
As used in this section: “In-network provider” means an individual or facility that contracts with a health benefit plan or health care service contractor to provide health care services to an individual insured under the health benefit plan or health care service contract. “Out-of-network provider” means an individual or facility that does not contract wi…
An insurer offering a policy or certificate of health insurance may not prohibit a hospital, as a condition of reimbursing a claim for hospital services, from paying or waiving all or a portion of a copayment or deductible owed by an insured under the policy or certificate. Note: 743B.290 was added to and made a part of the Insurance Code by legislative act…
As used in this section: “Enrollee” has the meaning given that term in ORS 743B.005. “Established local rate” means the rate established where the health care services originated for the provision of ground ambulance services through a publicly accessible process that includes an analysis of the cost to provide the ground ambulance services by: The local …
The Director of the Department of Consumer and Business Services shall adopt by rule requirements for disclosure by group and individual health insurers to individual and group health insurance policyholders the difference between coverage under the existing policy and coverage being offered to replace that coverage. The provisions of this section do not ap…
As used in this section, “rescind” means to retroactively cancel or discontinue coverage under a health benefit plan or group or individual health insurance policy for reasons other than failure to timely pay required premiums or required contributions toward the cost of coverage. An insurer may not rescind coverage of an individual under a health benefit p…
A group health insurance policy shall contain a provision allowing a minimum grace period of 10 days after the premium due date for payment of premium. An insurer of a group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, that seeks to terminate a polic…
ORS 743B.320 applies to multiple employer trusts when an employer ceases to participate therein.
Before a health insurer selling an individual policy or group health benefit plan may cancel a policy for nonpayment of premium, the insurer must mail a separate notice to the policyholder informing the policyholder that the premium was not received and that the policy will be terminated as of the premium due date if the premium is not received by the end of…
The Director of the Department of Consumer and Business Services shall adopt rules necessary for the implementation and administration of ORS 743B.323 and the amendments to ORS 743.417, 743.420, 743B.013, 743B.105, 743B.125 and 743B.320 by sections 9 to 14, chapter 943, Oregon Laws 2001. Note: 743B.324 was enacted into law by the Legislative Assembly but wa…
As used in this section, “health benefit plan” has the meaning given that term in ORS 743B.005. An insurer shall notify a policyholder in writing if the insurer cancels or does not renew the policyholder’s individual health benefit plan. The notice shall be sent to the policyholder’s last-known mailing address by first class mail in a specially marked envel…
Every group health insurance policy delivered or issued for delivery in this state shall contain in substance the following provisions, applicable to the coverage for hospital or medical services or expenses provided under the policy: A provision that, when the premium for the policy or any part thereof is paid by an employer under the terms of a collective…
Every group health insurance policy that provides coverage for hospital or medical services or expenses shall provide that the insurer shall continue its obligation for benefits under the policy for any person insured under the policy who is hospitalized on the date of termination if the policy is terminated and immediately replaced by a group health insuran…
Every policy of group health insurance delivered or issued for delivery in this state shall contain a provision applicable to the coverage for hospital or medical services or expenses provided under the policy that if an employee incurs an injury or illness for which a workers’ compensation claim is filed, that policy will continue in effect with respect to …
A group health insurance policy providing coverage for hospital or medical expenses, other than coverage limited to expenses from accidents or specific diseases, shall contain a provision that: The surviving spouse of a certificate holder may continue coverage under the policy, at the death of the certificate holder, with respect to the spouse and any depen…
As used in subsections (1) to (6) of this section, “plan administrator” means: The person designated as the plan administrator by the instrument under which the group health insurance plan is operated; or If no plan administrator is designated, the plan sponsor. Within 60 days of legal separation or the entry of a judgment of dissolution of marriage, a le…
If a legally separated, divorced or surviving spouse elects continuation of coverage under ORS 743B.344 (1) to (6): The monthly premium for the continuation shall not be greater than the amount that would be charged if the legally separated, divorced or surviving spouse were a current certificate holder of the group plan plus the amount that the group polic…
As used in this section: “Covered person” means an individual who was a certificate holder under a group health insurance policy: On the day before a qualifying event; and During the three-month period ending on the date of the qualifying event. “Qualified beneficiary” means: A spouse or dependent child of a covered person who, on the day before a quali…
All clinical decisions regarding length of stay in a health care facility as defined in ORS 442.015, transfer between levels of care and follow-up care shall be the decision of the treating provider in consultation with the patient, as appropriate. An insurer may not terminate or restrict the practice privileges of any provider solely on the basis of one or…
No insurer may terminate or otherwise financially penalize a provider for: Providing information to or communicating with a patient in a manner that is not slanderous, defamatory or intentionally inaccurate concerning: Any aspect of the patient’s medical condition; Any proposed treatment or treatment alternatives, whether covered by the insurer’s health b…
A medical services contract may not require the provider, as an element of the contract or as a condition of compensation for services, to agree: In the event of alleged improper medical treatment of a patient, to indemnify the other party to the medical services contract for any damages, awards or liabilities including but not limited to judgments, settlem…
As used in this section: “Contractual discount” means a percentage reduction, required under a contract with an insurer, in a vision care provider’s usual and customary rate for vision care services and materials. “Discount card” means a card or other purchasing mechanism or device that is not insurance or a discount medical plan, as defined in ORS 735.631…
An insurer shall provide a naturopathic physician the choice of applying to be credentialed by the insurer as a primary care provider or as a specialty care provider. To be credentialed by an insurer as a primary care provider, a naturopathic physician must meet the credentialing requirements as established by the insurer. Note: 743B.407 was added to and m…
Except in the case of misrepresentation, prior authorization determinations shall be subject to the following requirements: Prior authorization determinations relating to benefit coverage and medical necessity shall be binding on the insurer if obtained no more than 60 days prior to the date the service is provided. Prior authorization determinations relat…
All utilization review performed pursuant to a medical services contract to which an insurer is not a party shall comply with the following: The criteria used in the review process and the method of development of the criteria shall be made available for review to a party to such medical services contract upon request. A physician licensed under ORS 677.10…
All insurers offering a health benefit plan in this state that provide utilization review or have utilization review provided on their behalf shall file an annual summary with the Department of Consumer and Business Services that describes all utilization review policies, including delegated utilization review functions, and documents the insurer’s procedure…
The provisions of ORS 743B.001, 743B.220, 743B.405 and 743B.422 do not apply to medical services contracts for services to be provided under ORS chapter 656. Note: See note under 743B.405.
An insurer offering a health benefit plan may not: Require prior authorization: During the first 60 days of treatment, including medication therapy, prescribed for opioid or opiate withdrawal; or For post-exposure prophylactic antiretroviral drugs or preexposure prophylactic antiretroviral drugs, or drugs prescribed for the treatment of human immunodefici…
As used in this section: “Behavioral health benefits” means insurance coverage of mental health treatment and services and substance use disorder treatment and services. “Carrier” has the meaning given that term in ORS 743B.005. “Geographic region” means the geographic area of the state established by the Department of Consumer and Business Services for t…
An insurer offering a health benefit plan that requires prior authorization for surgical procedures may not require prior authorization for an additional or related health care procedure that is identified during the authorized surgical procedure if: The provider, while providing an approved surgical procedure, identifies a medical condition, disease or ail…
An insurer offering a health benefit plan in this state that provides utilization review or has utilization review provided on the insurer’s behalf shall utilize a prior authorization application programming interface as described in 45 C.F.R. 156.223(b), as in effect on February 28, 2024. The application programming interface shall enable a provider to: De…
Except as provided in this subsection, when a claim under a health benefit plan is submitted to an insurer by a provider on behalf of an enrollee, the insurer shall pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim. If an insurer requires additional information before payment of a claim, not lat…
As used in this section, “refund” means the return, either directly or through an offset to a future claim, of some or all of a payment already received by a health care provider. Except in the case of fraud or abuse of billing, and except as provided in subsections (3) and (5) of this section, a health insurer may not: Request from a health care provider …
An insurer that fails to pay a claim to a provider within the timelines established in ORS 743B.450 shall pay simple interest of 12 percent per annum on the unpaid amount of the claim that is due and owing, accruing from the date after the payment was due until the claim is paid. Interest on any overdue payment for a claim begins to accrue on the 31st day af…
Except in the case of fraud and except as provided in subsection (3) of this section, a health care provider may not: Request additional payment from a health insurer to satisfy a claim unless the provider: Requests the additional payment in writing on or before the last day of the period specified by the contract or 18 months after the date the claim was …
As used in this section: “Complete application” means a provider’s application to a health insurer to become a credentialed provider that includes: Information required by the health insurer; Proof that the provider is licensed by a health professional regulatory board as defined in ORS 676.160, the Long Term Care Administrators Board, the Board of Licens…
As used in this section, “dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit. A dental insurer may pay a claim for reimbursement made by a dental care provider using a credit card or electronic funds transfer payment method that imposes on the provider a fee or similar cha…
An insurer offering a health benefit plan, as defined in ORS 743B.005, that reimburses the costs of services provided by a national primary care medical home payment model, conducted by the Center for Medicare and Medicaid Innovation in accordance with 42 U.S.C. 1315a, that includes performance-based incentive payments for primary care, shall offer similar a…
An insurer may negotiate and enter into contracts for alternative rates of payment with providers to provide services covered by a group health insurance policy and may offer the benefit of such alternative rates to insureds who select such providers. An insurer may utilize such contracts by offering a choice of plans at the time an insured enrolls, one of w…
As used in this section: “Health benefit plan” has the meaning given that term in ORS 743B.005. “Provider” means a person licensed, certified or otherwise authorized or permitted by laws of this state to administer medical or mental health services, including substance use disorder services, in the ordinary course of business or practice of a profession. …
For the purposes of this section: “Health insurer” or “insurer” means an employee benefit plan, self-insured plan, managed care organization or group health plan, a third party administrator, fiscal intermediary or pharmacy benefit manager of the plan or organization, or other party that is by statute, contract or agreement legally responsible for payment o…
The Director of the Department of Consumer and Business Services shall by rule establish guidelines for the coordination of benefits for individual and group health insurance, including: The procedures by which persons insured under the policies are to be made aware of the existence of a coordination of benefits provision; The benefits which may be subject…
As used in this section and ORS 743B.501 to 743B.503: “Contracting entity” means any person that contracts directly with a provider for the delivery of health care services or contracts with a third party for the purpose of selling or making available to the third party the provider’s health care services or discounted rates or the services or rates of a pr…
A contracting entity that does not have a certificate of authority shall register with the Department of Consumer and Business Services as a contracting entity by submitting the following information to the department in written or electronic form as prescribed by the department along with any fee prescribed by the department: The official name of the entit…
A contracting entity or a third party may not contract with another third party to provide access to the health care services and discounted rates of a provider under a provider network contract unless: The third party contract is specifically authorized by the provider network contract; and The third party contract obligates the third party to comply with…
A contract between a third party and a contracting entity or between two third parties with respect to a provider network contract must comply with this section and ORS 743B.502. A third party shall inform the contracting entity and providers under a contracting entity’s provider network contract of a website, toll-free number or other readily available mec…
As used in this section: “Dental insurer” means an insurer that offers a policy or certificate of insurance or other contract, that provides only a dental benefit. “Material modification” includes, but is not limited to, changes to the terms or conditions of a contract that alter: Reimbursement rates paid to dental care providers; Fee schedules for denta…
A carrier offering an individual or group health benefit plan in this state that provides coverage through a specified network of health care providers shall: Contract with or employ a network of providers that is sufficient in number, geographic distribution and types of providers to ensure that all covered services under the health benefit plan, including…
Nothing in ORS 743.008, 743A.012, 743B.195, 743B.197, 743B.200, 743B.202, 743B.204, 743B.250, 743B.400, 743B.403, 743B.420, 743B.423 and 743B.550 shall be construed to require disclosure of information that is otherwise privileged or confidential under any other provision of law.
As used in this section: “Carrier” has the meaning given that term in ORS 743B.005. “Communication” includes: An explanation of benefits notice; Information about an appointment; A notice of an adverse benefit determination; A carrier’s or third party administrator’s request for additional information regarding a claim; A notice of a contested claim; …
As used in this section: “Health plan” means: A “health benefit plan” as defined in ORS 743B.005; and A self-insured health plan offered by the Oregon Health and Science University. “Synchronization policy” means a procedure for aligning the refill dates of a patient’s prescription drugs so that drugs that are refilled at the same frequency may be refill…
As used in this section: “Beneficiary” means an individual receiving health care that is provided or reimbursed by an entity that provides health care coverage. “Health care coverage” includes any of the following that reimburse the cost of prescription drugs: A health benefit plan; An insurance policy or certificate; A medical services contract; A mul…
As used in this section: “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: Has an identical amount of the same active chemical ingredients and the same dosage form; and If administer…
As used in this section: “Clinically appropriate” means supported by nationally recognized compendia, clinical guidelines or generally recognized standards of care. “Compendia” means those resources widely accepted by the medical profession in the efficacious use of drugs. “Health care coverage” has the meaning given that term in ORS 743B.602. “Nonopioid…
As used in this section: “Administer” means to directly apply a drug to the body of a patient by injection, inhalation, ingestion or any other means. “Clinician-administered drug” means an outpatient prescription drug that: Cannot reasonably be: Administered by a patient for whom the drug is prescribed; or Administered by an individual other than a heal…
As used in this section, “health benefit plan” means a health benefit plan, as defined in ORS 743B.005, that is offered in the individual or small group market. The Department of Consumer and Business Services may establish by rule a procedure for adjusting risk between insurers. If a procedure is established: The procedure may include: An assessment impo…
A health benefit plan may not exclude, and shall expedite preauthorizations required for, work-related injuries or occupational diseases if: The injured worker is covered by workers’ compensation insurance and the health benefit plan; and The injured worker has submitted a workers’ compensation claim for the work-related injury or occupational disease that…