1. (1) As used in this section:

   1. (a) “Administer” means to directly apply a drug to the body of a patient by injection, inhalation, ingestion or any other means.

   2. (b)

      1. (A) “Clinician-administered drug” means an outpatient prescription drug that:

         1. (i) Cannot reasonably be:
         2. (I) Administered by a patient for whom the drug is prescribed; or
         3. (II) Administered by an individual other than a health care provider who is assisting the patient with the self-administration of the drug; and
         4. (ii) Is typically administered in the office of an enrollee’s physician or another of the enrollee’s health care providers authorized by law to administer the drug.

      2. (B) “Clinician-administered drug” does not include a:

         1. (i) Vaccine;
         2. (ii) Drug administered through a clinic affiliated with a hospital;
         3. (iii) Drug administered in a hospital; or
         4. (iv) Drug administered in an outpatient infusion center that is in a hospital or that is affiliated with a hospital.
   3. (c) “Health benefit plan” has the meaning given that term in ORS 743B.005.
   4. (d) “Health care provider” means an individual who is licensed, certified or otherwise authorized to provide health care services in this state.

2. (2) Subject to subsection (3) of this section, a health benefit plan that reimburses the cost of hospital or medical expenses may not, for a covered clinician-administered drug for the treatment of cancer or a covered drug administered by an enrollee’s oncology clinic to treat a symptom, complication or consequence of cancer:

   1. (a) Require the drug to be dispensed only by certain pharmacies or only by pharmacies participating in the health benefit plan issuer’s provider network;
   2. (b) Limit or deny coverage of the drug based on the enrollee’s choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer’s provider network;

   3. (c) Require a physician or health care provider participating in the health benefit plan issuer’s provider network to bill for or be reimbursed for the delivery and administration of the drugs as a pharmacy benefit instead of as a medical benefit under the plan unless:

      1. (A) The patient has provided informed written consent; and
      2. (B) The patient’s physician or health care provider attests in writing that a delay in the administration of the drug will not place the patient at an increased health risk; or
   4. (d) Require the enrollee to pay an additional fee or other increased cost for the drug based on the enrollee’s choice of pharmacy or because the drug was not dispensed by a pharmacy that participates in the health benefit plan issuer’s provider network.

3. (3) Subsection (2) of this section applies to a drug only if the enrollee’s physician or health care provider determines that:

   1. (a) A delay in care would make disease progression probable;

   2. (b) The use of a pharmacy within the health benefit plan issuer’s provider network would:

      1. (A) Make death or patient harm probable; or
      2. (B) Potentially cause a barrier to the enrollee’s adherence to or compliance with the enrollee’s plan of care; or
   3. (c) The timeliness of the delivery or dosage requirements necessitate delivery by a pharmacy that is outside of the health benefit plan issuer’s provider network.

4. (4) This section does not:

   1. (a) Authorize a person to administer a drug when otherwise prohibited by state or federal law; or
   2. (b) Modify drug administration requirements under state law, including any requirements related to the delegation and supervision of the administration of drugs.

Note: 743B.610 was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743B or any series therein. See Preface to Oregon Revised Statutes for further explanation.

[2024 c.24 §2]