Oklahoma § 36-6060.5 - Oklahoma Breast Cancer Patient Protection Act

§ 36-6060.5. Oklahoma Breast Cancer Patient Protection Act

A. This section shall be known and may be cited as the

"Oklahoma Breast Cancer Patient Protection Act".

B. Any health benefit plan that is offered, issued or renewed

in this state on or after January 1, 1998, that provides medical and

surgical benefits with respect to the treatment of breast cancer and

Oklahoma Statutes - Title 36. Insurance

other breast conditions shall ensure that coverage is provided for

not less than forty-eight (48) hours of inpatient care following a

mastectomy and not less than twenty-four (24) hours of inpatient

care following a lymph node dissection for the treatment of breast

cancer.

C. Nothing in this section shall be construed as requiring the

provision of inpatient coverage where the attending physician in

consultation with the patient determines that a shorter period of

hospital stay is appropriate.

D. Any plan subject to subsection B of this section shall also

provide coverage for reconstructive breast surgery performed as a

result of a partial or total mastectomy. Because breasts are a

paired organ, any such reconstructive breast surgery shall include

coverage for all stages of reconstructive breast surgery performed

on a nondiseased breast to establish symmetry with a diseased breast

when reconstructive surgery on the diseased breast is performed,

provided that the reconstructive surgery and any adjustments made to

the nondiseased breast must occur within twenty-four (24) months of

reconstruction of the diseased breast.

E. In implementing the requirements of this section, a health

benefit plan may not modify the terms and conditions of coverage

based on the determination by an enrollee to request less than the

minimum coverage required pursuant to subsections B and D of this

section.

F. A health benefit plan shall provide notice to each insured

or enrollee under the plan regarding the coverage required by this

section in the evidence of coverage of the plan, and shall provide

additional written notice of the coverage to the insured or enrollee

as follows:

1. In the next mailing made by the plan to the employee;

2. As part of any yearly informational packet sent to the

enrollee; or

3. Not later than December 1, 1997;

whichever is earlier.

G. As used in this act, "health benefit plan" means any plan or

arrangement as defined in subsection C of Section 6060.4 of this

title.

H. The Insurance Commissioner shall promulgate any rules

necessary to implement the provisions of this section.

Added by Laws 1997, c. 135, § 1, eff. Nov. 1, 1997. Amended by Laws

2003, c. 464, § 7, eff. July 1, 2003; Laws 2010, c. 222, § 35, eff.

Nov. 1, 2010.

§36-6060.5a. Biomarker testing.

A. As used in this section:

1. "Biomarker" means a biological molecule found in blood,

other body fluids, or tissues that is a sign of a normal or abnormal

Oklahoma Statutes - Title 36. Insurance

process, or of a condition or disease. A biomarker may be used to

see how well the body responds to a treatment for a disease or

condition or for other purposes. Biomarkers shall include but are

not limited to gene mutation or protein expression;

2. "Biomarker testing" means the analysis of a patient’s

tissue, blood, or other biospecimen for the presence of a biomarker.

Biomarker testing shall include but not be limited to single-analyte

tests, multiplex panel tests, gene or protein expression, and whole

exome, whole genome, and whole transcriptome sequencing;

3. "Clinical utility" means the test result provides

information that is used in the formulation of a treatment or

monitoring strategy that informs a patient's outcome and impacts the

clinical decision. The most appropriate test may include both

information that is actionable and some information that cannot be

immediately used in the formulation of a clinical decision;

4. "Consensus statement" means a statement that:

a.

is developed by an independent, multidisciplinary

panel of experts that use a transparent methodology

and reporting structure that includes a conflict of

interest policy,

b.

is based on the best available evidence for the

purpose of optimizing clinical care outcomes, and

c.

is aimed at specific clinical circumstances;

5. "Health benefit plan" means a plan as defined pursuant to

Section 6060.4 of Title 36 of the Oklahoma Statutes; and

6. "Nationally recognized clinical practice guidelines" means

evidence-based clinical practice guidelines that:

a.

are developed by independent organizations or medical

professional societies using a transparent methodology

and reporting structure and a conflict of interest

policy, and

b.

establish standards of care that are informed by a

systemic review of evidence and an assessment of the

benefits and costs of alternative care options that

includes recommendations intended to optimize patient

care.

B. Any health benefit plan, including the Oklahoma Employees

Insurance Plan, that is offered, issued, or renewed in this state on

or after the effective date of this act shall provide coverage for

biomarker testing. A contract provided with a health benefit plan

under this section shall include biomarker testing for the purpose

of diagnosis, treatment, appropriate management, or ongoing

monitoring of an insured’s disease or condition to guide treatment

decisions when the biomarker test provides clinical utility as

demonstrated by medical and scientific evidence including, but not

limited to:

Oklahoma Statutes - Title 36. Insurance

1. Labeled indications for tests that are approved or cleared

by the United States Food and Drug Administration;

2. Indicated tests for a drug that is approved by the United

States Food and Drug Administration;

3. Warnings and precautions on United States Food and Drug

Administration-approved drug labels;

4. Centers for Medicare and Medicaid Services national coverage

determinations or Medicare administrative contractor local coverage

determinations; or

5. Nationally recognized clinical practice guidelines and

consensus statements.

C. A health benefit plan shall ensure that coverage is provided

in a manner that limits disruptions in care, including the need for

multiple biopsies and biospecimen samples.

D. An insured and a prescribing practitioner shall have access

to a clear, readily available, and convenient process to request an

exception to a coverage policy of a health benefit plan under this

subsection. The process shall be readily accessible on the plan’s

website. This subsection shall not be construed to require a

separate process if the health benefit plan’s existing process

complies with this subsection.

Added by Laws 2023, c. 331, § 1, eff. Jan. 1, 2024.

§36-6060.5b. Clinical genetic testing coverage.

A. For the purposes of this section:

1. “Clinical utility” means clinical utility as defined

pursuant to Section 6060.5a of Title 36 of the Oklahoma Statutes;

2. “Evidence-based cancer imaging” means appropriate

preventative screening and imaging supported by evidence;

3. “Genetic testing for an inherited mutation” means multi-gene

testing for an inherited mutation associated with an increased risk

of cancer;

4. “Health benefit plan” means a health benefit plan as defined

pursuant to Section 6060.4 of Title 36 of the Oklahoma Statutes; and

5. “Health care provider” means any physician, hospital, or

other entity or person that is licensed or otherwise authorized in

this state to furnish health care services.

B. Any health benefit plan including the Oklahoma Employees

Insurance Plan that is offered, issued, or renewed in this state on

or after the effective date of this act shall provide coverage for:

1. Clinical genetic testing for an inherited gene mutation for

individuals with a personal or family history of cancer when such

test provides clinical utility and when ordered or recommended by a

health care provider in accordance with medical and scientific

evidence including, but not limited to:

Oklahoma Statutes - Title 36. Insurance

a.

the most recent version of the National Comprehensive

Cancer Network (NCCN) clinical practice

recommendations that are Category 2A or higher,

b.

Centers for Medicare and Medicaid Services national

coverage determinations or Medicare administrative

contractor local coverage determinations, or

c.

nationally recognized clinical practice guidelines;

and

2. Evidence-based cancer imaging for individuals with an

increased risk of cancer when such test provides clinical utility

and when ordered or recommended by a health care provider in

accordance with the most recent version of the NCCN clinical

practice recommendations that are Category 2A or higher, or in

accordance with other nationally recognized clinical practice

guidelines.

C. Coverage under this section shall not be subject to any

annual deductibles, copayments, or coinsurance limits as established

for all covered benefits under the health benefit plan.

D. If application of this section would result in health

savings account ineligibility under Section 223 of the Internal

Revenue Code of 1986, as amended, the provisions of this section

shall only apply to health savings accounts with qualified high

deductible health plans with respect to the deductible of such a

plan after the enrollee has satisfied the minimum deductible.

Provided, however, the provisions of this section shall apply to

items or services that are preventive care pursuant to Section

223(c)(2)(C) of the Internal Revenue Code of 1986, as amended,

regardless of whether the minimum deductible has been satisfied.

Added by Laws 2025, c. 395, § 1, eff. Nov. 1, 2025.