44-7,112. Terms, defined.
For purposes of the Step-Therapy Reform Act:
(1) Clinical practice guidelines means a systematically developed statement to assist decisionmaking by health care providers and decisions by covered persons about appropriate health care for specific clinical circumstances and conditions;
(2) Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health carrier or utilization review organization to determine the medical necessity and appropriateness of health care services;
(3) Health carrier means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the Director of Insurance, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including a sickness and accident insurance company, a health maintenance organization, a nonprofit hospital and health service corporation, or any other entity providing a plan of health insurance, health benefits, or health care services. Health carrier does not include a managed care organization;
(4) Pharmaceutical sample means a unit of a prescription drug that is not intended to be sold and is intended to promote the sale of the drug;
(5) Step-therapy override exception means that a step-therapy protocol should be overridden in favor of coverage of the prescription drug selected by a health care provider within the applicable timeframes, based on a review of the request of the health care provider or covered person for an override, along with supporting rationale and documentation;
(6) Step-therapy protocol means a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition and medically appropriate for a particular covered person are covered under a pharmacy or medical benefit by a health carrier or a utilization review organization, including self-administered drugs and drugs administered by a health care provider; and
(7) Utilization review organization means an entity that conducts a utilization review other than a health carrier performing a review for its own health benefit plans.
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