Arkansas Code of 1987 (2023) › Title 23 - PUBLIC UTILITIES AND REGULATED INDUSTRIES (§§ 23-1-101 — 23-119-105) › Subtitle 3 - INSURANCE (§§ 23-60-101 — 23-103-417) › Chapter 79 - INSURANCE POLICIES GENERALLY (§§ 23-79-101 — 23-79-2802) › Subchapter 21 - REGULATION OF STEP THERAPY PROTOCOLS (§§ 23-79-2101 — 23-79-2105) › Section 23-79-2102 - Definitions

As used in this subchapter:
(1)
"Clinical practice guidelines" means a systematically developed statement derived from peer-reviewed published medical literature, evidence-based research, and widely accepted medical practice to assist decision-making by healthcare providers and patients 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 healthcare insurer, health benefit plan, or utilization review organization to determine the medical necessity and appropriateness of healthcare services;
(3)
"Generic equivalent" means an AB-rated drug that is pharmaceutically and therapeutically equivalent to the drug prescribed;
(4)
(A)
"Health benefit plan" means an individual, blanket, or any group plan, policy, or contract for healthcare services issued, renewed, or extended in this state by a healthcare insurer, health maintenance organization, hospital medical service corporation, or self-insured governmental or church plan in this state.
(B)
"Health benefit plan" includes:
(i)
Indemnity and managed care plans;
(ii)
Plans providing health benefits to state and public school employees under §
21-5-401
et seq.; and
(iii)
Individual qualified health insurance plans under the Arkansas Health and Opportunity for Me Act of 2021, §
23-61-1001
et seq.
(C)
"Health benefit plan" does not include:
(i)
A disability income plan;
(ii)
A credit insurance plan;
(iii)
Insurance coverage issued as a supplement to liability insurance;
(iv)
Medical payments under an automobile or homeowners insurance plan;
(v)
A health benefit plan provided under Arkansas Constitution, Article 5, § 32, the Workers' Compensation Law, §
11-9-101
et seq., and the Public Employee Workers' Compensation Act, §
21-5-601
et seq.;
(vi)
A plan that provides only indemnity for hospital confinement;
(vii)
An accident-only plan;
(viii)
A specified disease plan;
(ix)
A plan that provides only dental benefits or eye and vision care benefits; or
(x)
A program or plan authorized under
42 U.S.C. § 1396a
et seq., as it existed on January 1, 2021, as approved by the United States Secretary of Health and Human Services, excluding individual qualified health insurance plans under the Arkansas Health and Opportunity for Me Act of 2021, §
23-61-1001
et seq.;
(5)
(A)
"Healthcare insurer" means an insurance company, hospital and medical service corporation, or health maintenance organization that issues or delivers health benefit plans in this state and is subject to any of the following laws:
(i)
The insurance laws of this state;
(ii)
Section
23-75-101
et seq., pertaining to hospital and medical service corporations; or
(iii)
Section
23-76-101
et seq., pertaining to health maintenance organizations.
(B)
"Healthcare insurer" does not include an entity that provides only dental benefits or eye and vision care benefits;
(6)
"Interchangeable biological product" means a biological product that is interchangeable, as "interchangeable" is defined by
42 U.S.C. § 262(i)(3)
, as it existed on January 1, 2021;
(7)
"Medically necessary" means healthcare services and supplies that, under the applicable standard of care, are appropriate:
(A)
To improve or preserve health, life, or function;
(B)
To slow the deterioration of health, life, or function; or
(C)
For the early screening, prevention, evaluation, diagnosis, or treatment of a disease, condition, illness, or injury;
(8)
"Step therapy protocol" means a protocol, policy, or program that establishes the specific sequence in which prescription drugs for a specified medical condition and that are medically appropriate for a patient are covered by a healthcare insurer or health benefit plan;
(9)
"Step therapy protocol exception" means that a step therapy protocol is overridden in favor of immediate coverage of the healthcare provider's selected prescription drug; and
(10)
(A)
"Utilization review organization" means an individual or entity that performs step therapy for at least one (1) of the following:
(i)
A healthcare insurer;
(ii)
A preferred provider organization or health maintenance organization; or
(iii)
Any other individual or entity that provides, offers to provide, or administers hospital, outpatient, medical, or other health benefits to a person treated by a healthcare provider in this state under a policy, health benefit plan, or contract.
(B)
A healthcare insurer is a utilization review entity if the healthcare insurer performs step therapy.
(C)
"Utilization review organization" does not include an insurer of automobile, homeowners, or casualty and commercial liability insurance or the insurer's employees, agents, or contractors.
Amended by Act 2021, No. 645,§ 1, eff. 7/28/2021.
Added by Act 2021, No. 97,§ 2, eff. 1/1/2022.