Chapter 743A — Health Insurance: Reimbursement of Claims

ORS 743A.062 Prescription drugs

(1)

As used in this section, “medical assistance program” means the state program that provides medical assistance as defined in ORS 414.025.

(2)

An insurance policy or contract providing coverage for a prescription drug to a resident of this state may not:

(a)

Exclude coverage of the drug for a particular indication solely on the grounds that the indication has not been approved by the United States Food and Drug Administration if the Health Evidence Review Commission established under ORS 414.688 or the Pharmacy and Therapeutics Committee established under ORS 414.353 determines that the drug is recognized as effective for the treatment of that indication:

(A)

In publications that the commission or the committee determines to be equivalent to:

(i)

The American Hospital Formulary Service drug information;

(ii)

“Drug Facts and Comparisons” (Lippincott-Raven Publishers);

(iii)

The United States Pharmacopoeia drug information; or

(iv)

Other publications that have been identified by the United States Secretary of Health and Human Services as authoritative;

(B)

In the majority of relevant peer-reviewed medical literature; or

(C)

By the United States Secretary of Health and Human Services; or

(b)

For an insured who is enrolled in the medical assistance program:

(A)

Except as provided in subsection (3) of this section, require a prescription for the drug to be filled or refilled at a mail order pharmacy; or

(B)

Require a prescription for the drug to be filled or refilled at a pharmacy that is not a local pharmacy enrolled in the medical assistance program.

(3)

Subsection (2)(b)(A) of this section does not prohibit an insurer from requiring a medical assistance recipient to fill or refill a prescription for a specialty drug at a mail order pharmacy that is a specialty pharmacy.

(4)

Required coverage of a prescription drug under this section shall include coverage for medically necessary services associated with the administration of that drug.

(5)

Nothing in this section requires coverage for any prescription drug if the United States Food and Drug Administration has determined use of the drug to be contraindicated.

(6)

Nothing in this section requires coverage for experimental drugs not approved for any indication by the United States Food and Drug Administration.

(7)

This section is exempt from ORS 743A.001.