State Law

Ohio Revised Code-Title XXXIX-Chapter 3901. Superintendent of Insurance

08/17/2023 Ohio Section 3901.83

Definitions for sections 3901.83 to 3901.833

Step Therapy Override, U.R. Criteria

See bold text below:

As used in sections 3901.83 to 3901.833 of the Revised Code:

(A) “Clinical practice guidelines” means a systematically developed statement to assist health care provider and patient decisions with regard to appropriate health care for specific clinical circumstances and conditions.

U.R. Criteria

(B) “Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols, and clinical practice guidelines used by a health plan issuer or utilization review organization to determine whether or not health care services or drugs are appropriate and consistent with medical or scientific evidence.

(C) “Health benefit plan” and “health plan issuer” have the same meanings as in section 3922.01 of the Revised Code.

(D) “Medical or scientific evidence” has the same meaning as in section 3922.01 of the Revised Code.

Step Therapy Override

(E) “Step therapy exemption” means an overriding of a step therapy protocol in favor of immediate coverage of the health care provider’s selected prescription drug.

(F) “Step therapy protocol” means a protocol or program that establishes a specific sequence in which prescription drugs that are for a specified medical condition and that are consistent with medical or scientific evidence for a particular patient are covered, under either a medical or prescription drug benefit, by a health benefit plan, including both self-administered and physician-administered drugs.

(G) “Urgent care services” has the same meaning as in section 3923.041 of the Revised Code.

(H) “Utilization review organization” has the same meaning as in section 1751.77 of the Revised Code.