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, 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 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; 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.
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