OAR 836-053-1020
Drug Formularies

(1)

For purposes of OAR 836-053-0000 (Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53) to 836-053-1200 (Prior Authorization Requirements for Health Benefit Plans):

(a)

“Open formulary” means a method used by an insurer to provide prescription drug benefits in which all prescribed FDA approved prescription drug products are covered except for any drug product that is excluded by the insurer pursuant to the insurer’s policy regarding medical appropriateness or by the terms of a specific health benefit plan, or except for an entire class of drug product that is excluded by the insurer.

(b)

“Closed formulary” means a method used by an insurer to provide prescription drug benefits in which only specified FDA approved prescription drug products are covered, as determined by the insurer, but in which medical exceptions are allowed. Maximum benefits or coverage may be limited to formulary drugs in a health benefit plan with a closed formulary. [; and]

(c)

“Mandatory closed formulary” means a method used by an insurer to provide prescription drug benefits in which only specified FDA approved prescription drug products are covered, as determined by the insurer, and in which no exceptions are allowed.

(2)

An insurer that uses an open formulary must have a written procedure that includes the written criteria or explains the review process established by the insurer for determining when an item will be limited or excluded pursuant to the insurer’s policy regarding medical appropriateness.

(3)

An insurer that uses a closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary. The procedure must also describe how the insurer determines the content of the closed formulary and how the insurer determines the application of a medical exception. The procedure must describe how a provider may request inclusion of a new item in the closed formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(4)

An insurer that uses a mandatory closed formulary must have a written procedure stating that FDA approved prescription drug products are covered only if they are listed in the formulary and that no exception is allowed. The procedure must describe how the insurer determines the content of the mandatory closed formulary. The procedure must also describe how a provider may request inclusion of a new item in the formulary and must ensure that the insurer will issue a timely written response to a provider making such a request.

(5)

An insurer must furnish a copy of the procedures it has adopted under section (2), (3) or (4) of this rule to a provider with authority to prescribe drugs and medications, upon the request of the provider.

(6)

Except as provided in section (7) of this rule, a formulary must comply with the requirements of 45 CFR 156.122 and include the greater of:

(a)

At least one drug in every United States Pharmacopeia therapeutic category and class; or

(b)

The same number of drugs in each United States Pharmacopeia category and class as the prescription drug benefit of the plan described in OAR 836-053-0008 (Essential Health Benefits for Plan Years 2014, 2015 and 2016)(1)(a).

(7)

An insurer that issues a small group or individual health benefit plan formulary that does not comply with the requirements of section (6) of this rule must file with the Director of the Department of Consumer and Business Services the form entitled “Formulary-Inadequate Category/Class Count Justification” as set forth on the website of the Department of Consumer and Business Services at www.insurance.oregon.gov. The director, in the director’s discretion, may consider approval of a formulary that does not meet the requirements of section (5) of this rule if:

(a)

Drugs in a category or class have been discontinued by the manufacturer;

(b)

Drugs in a category or class have been deemed unsafe by the Food and Drug Administration or removed from market by the manufacturer due to safety concerns;

(c)

Drugs in a category of class have a Drug Efficacy Study Implementation classification;

(d)

Drugs in a category or class have become available as generics; or

(e)

Drugs in a category or class are provided in a medical setting and are covered under the medical provisions of the plan.

(8)

An insurer that issues a small group or individual health benefit plan formulary does not comply with the nondiscrimination requirements of OAR 836-053-0012 (Essential Health Benefits for Plan Years Beginning on and after January 1, 2017) if most or all drugs to treat a specific condition are placed in the highest cost tier.

(9)

A health benefit plan providing essential health benefits must have procedures in place that allow an enrollee to request and gain access to clinically appropriate prescription drugs not covered by the health plan.

(10)

An insurer may file a Bronze or Silver standard plan that substitutes a different prescription drug benefit from the prescription drug benefit described in the benchmark plan, provided that the insurer demonstrates that its proposed benefit complies with the prescription drug formulary requirements and will have a Bronze or Silver actuarial value.

Source: Rule 836-053-1020 — Drug Formularies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=836-053-1020.

836–053–0000
Applicability of January 1, 2014 Amendments to OAR Chapter 836, Division 53 836–053–0001
Modification of Health Benefit Plan Not Subject to Level of Coverage Requirements 836–053–0002
Modification of a Health Benefit Plan Subject to Levels of Coverage Requirements 836–053–0003
Prohibition of Exclusion Period for Pregnancy 836–053–0004
Compliance with Federal and State Law 836–053–0005
Prescription Drug Identification Cards 836–053–0007
Approval and Certification of Associations, Trusts, Discretionary Groups and Multiple Employer Welfare Arrangements 836–053–0008
Essential Health Benefits for Plan Years 2014, 2015 and 2016 836–053–0009
Oregon Standard Bronze and Silver Health Benefit Plans for Plan Years 2014, 2015 and 2016 836–053–0011
Standard Bronze Plan Health Savings Account Eligible Requirement 836–053–0012
Essential Health Benefits for Plan Years Beginning on and after January 1, 2017 836–053–0013
Oregon Standard Bronze and Silver Health Benefit Plans 836–053–0014
Standards and Process for Shortened Period of Market Prohibition 836–053–0015
Definition of Small Employer 836–053–0017
Additions to Essential Health Benefits for Plan Years Beginning on and after January 1, 2022 836–053–0019
Purpose 836–053–0021
Plans Offered to Oregon Small Employers 836–053–0030
Marketing of a Health Benefit Plan to Small Employers 836–053–0050
Trade Practices Relating to Small Employer Health Benefit Plans 836–053–0063
Rating for Nongrandfathered Small Group Plans 836–053–0065
Rating for Grandfathered Small Group Plans 836–053–0066
Rating for Transitional Health Benefit Plans Offered to Small Employers 836–053–0070
Multiple Employer Welfare Arrangements 836–053–0100
Work Related Injuries or Disease 836–053–0105
Coordination of Payment for Interim Medical Services 836–053–0211
Underwriting, Enrollment and Benefit Design Requirements Applicable to A Group Health Benefit Plan Including A Small Group Health Benefit Plan 836–053–0221
Participation, Contribution, and Eligibility Requirements for Group Health Benefit Plans Including Small Group Health Benefit Plans 836–053–0230
Underwriting 836–053–0300
Purpose 836–053–0310
Network Adequacy Definitions for OAR 836-053-0300 to 836-053-0350 836–053–0320
Annual Report Requirements for Network Adequacy 836–053–0330
Nationally Recognized Standards for Use in Demonstrating Compliance with Network Adequacy Requirements 836–053–0340
Factor-Based Evidence of Compliance with Network Adequacy Requirements 836–053–0350
Provider Directory Requirements for Network Adequacy 836–053–0410
Purpose 836–053–0415
Cancellation of an Individual Health Benefit Plan Coverage 836–053–0418
Definition of Insurer for Reimbursement of Expenses Related to Disease Outbreak or Epidemic 836–053–0431
Underwriting, Enrollment and Benefit Design 836–053–0435
Health Benefit Plan Coverage of Well-woman Preventive Care Services 836–053–0465
Rating for Individual Health Benefit Plans 836–053–0472
Statutory Authority and Implementation 836–053–0473
Required Materials for Rate Filing for Individual or Small Employer Health Benefit Plans 836–053–0474
Process For Rate Filing for Individual and Small Employer Health Benefit Plans 836–053–0475
Approval, Disapproval or Modification of Premium Rates for Individual or Small Employer Health Benefit Plan 836–053–0510
Evaluating the Health Status of an Applicant for Individual Health Benefit Plan Coverage 836–053–0600
Purpose 836–053–0605
Definitions for OAR 836-053-0600 to 836-053-0615 836–053–0610
Carrier Response to Request for Confidentiality 836–053–0615
Carrier Reporting Requirements 836–053–0825
Rescission of a Group Health Benefit Plan 836–053–0830
Rescission of an Individual Health Benefit Plan or Individual Health Insurance Policy 836–053–0835
Rescission of an Individual’s Coverage under a Group Health Benefit Plan or Group Health Insurance Policy 836–053–0851
Purpose 836–053–0857
Definitions 836–053–0863
Notifications 836–053–0900
Purpose 836–053–0910
Rate Filing 836–053–1000
Statutory Authority and Implementation 836–053–1010
Insurer Policies 836–053–1020
Drug Formularies 836–053–1030
Written Information to Enrollees 836–053–1033
Cultural and Linguistic Appropriateness 836–053–1035
Summary of Benefits and Explanation of Coverage 836–053–1060
Definitions 836–053–1070
Reporting of Grievances 836–053–1080
Tracking Grievances 836–053–1090
Assistance in Filing Grievances 836–053–1100
Internal Appeals Process 836–053–1110
Notice of Complaint Filing with Director 836–053–1130
Annual Summary, Utilization Review 836–053–1140
Appeal and Utilization Review Determinations 836–053–1170
Annual Summary, Quality Assessment Activities 836–053–1180
Format and Instructions for Report Required by ORS 743.818 836–053–1190
Annual Summary, Uniform Indicators of Network Adequacy 836–053–1200
Prior Authorization Requirements for Health Benefit Plans 836–053–1203
Prior Authorization Trade Practices for Health Insurance other than Health Benefit plans 836–053–1205
Uniform Prescription Drug Prior Authorization Request Form 836–053–1300
Purpose and Scope 836–053–1305
Definitions 836–053–1310
Contracting Requirements 836–053–1315
Performance Criteria 836–053–1317
Professional Qualifications 836–053–1320
Conflict of Interest 836–053–1325
Procedures for Conducting External Reviews 836–053–1330
Criteria and Considerations for External Review Determinations 836–053–1335
Procedures for Complaint Investigation 836–053–1337
Preliminary Review by Insurer 836–053–1340
Timelines and Notice for Dispute That is Not Expedited 836–053–1342
Timelines and Notice for Expedited Decision-Making 836–053–1345
Quality Assurance Mechanisms 836–053–1350
Ongoing Requirements for Independent Review Organizations 836–053–1355
Synopses 836–053–1360
External Review Reporting 836–053–1365
Fees for External Reviews 836–053–1400
Format and Instructions for Report Required by ORS 743.748 836–053–1403
Definitions of Coordinated Care and Case Management for Behavioral Health Care Services 836–053–1404
Definitions 836–053–1405
General Requirements for Coverage of Mental or Nervous Conditions and Chemical Dependency 836–053–1407
Prohibited Exclusions 836–053–1408
Required Disclosures 836–053–1409
Definitions 836–053–1410
Procedures 836–053–1415
Instructions 836–053–1500
Purpose 836–053–1505
Definitions for OAR 836-053-1500 to 836-053-1510 836–053–1510
Prominent Carrier Reporting Requirements 836–053–1520
Purpose 836–053–1525
Definitions 836–053–1530
Reporting Requirements 836–053–1600
Purpose 836–053–1605
Definitions for 836-053-1600 to 836-053-1615 836–053–1610
Non-anesthesia-related claims 836–053–1615
Anesthesia-related claims
Last Updated

Jun. 8, 2021

Rule 836-053-1020’s source at or​.us