Director's expectations for health benefit plans under the Oregon Reproductive Health Equity Act
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Director's expectations for health benefit plans in Oregon to provide reproductive health services, drugs, devices, products, and procedures described in ORS 743A.067 without cost sharing, and guidance on permissible management and exceptions. Applies to all entities offering health benefit plans in Oregon.
No material clinical or coverage changes in this revision.
Coverage Criteria for Reproductive Health Services
Preventive and screening services
Covered when services fall within ORS 743A.067(2) and applicable USPSTF/HRSA recommendations, without limitation by sex or gender.
Plans compliant if they cover USPSTF/HRSA required services without sex/gender limits.
Contraceptive coverage
Covered without cost sharing: all FDA-approved contraceptive drugs, devices, and products, including when prescribed for non-contraceptive medical reasons.
Includes contraceptives prescribed for reasons other than preventing pregnancy and those necessary to preserve life or health.
Plans that limit therapeutic equivalents must still provide alternatives when medically inadvisable for a particular enrollee.
Carrier processes should account for medical exigencies and not be unduly burdensome; director expects carriers to defer to provider determinations except as allowed under ORS 743A.067(7).
Reasonable medical management (non-contraception/non-abortion)
Permitted limits and scope of reasonable medical management for services other than contraception and abortion.
Techniques inconsistent with RHEA include strict numerical limits that ignore medical need and denying services because the enrollee's sex or gender differs from typical USPSTF/HRSA recommendations (e.g., limiting STI screening to once per year when more frequent testing is medically appropriate).
Contraceptive coverage and utilization management
Carriers must cover FDA-approved contraceptives and defer to provider-determined medically appropriate alternatives; utilization management constraints and operational expectations are as follows:
These expectations implement ORS 743A.067(2)(j)(A)–(D) and the director's interpretations in this bulletin.
Abortion coverage
Abortion coverage under RHEA and applicable limitations.
Carriers should not impose restrictions or delays not explicitly authorized by RHEA.
HDHP/HSA compatibility
Guidance on High Deductible Health Plans (HDHPs) and HSA eligibility when accommodating RHEA-covered services.
Ensures HDHPs can remain HSA-eligible while accommodating state mandates to the extent not conflicting with federal law.
CMP cost sharing
Cost-sharing treatment for Comprehensive Metabolic Panels (CMPs).
Standard cost sharing may apply when a CMP is not tied to a preventive service.
RHEA does not require coverage for every health care intervention. Under ORS 743A.067(7), a health benefit plan may exclude coverage for experimental or investigational treatments, clinical trials or demonstration projects (except as provided in ORS 743A.192), treatments that do not conform to acceptable and customary standards of medical practice, treatments for which there is insufficient medical evidence of efficacy, or abortion when the carrier is exempt. When a carrier denies coverage for a RHEA-listed service for one of these reasons, the carrier is expected to document the rationale for the denial and provide the enrollee with the appeal rights required under ORS 743B.250.
Carriers may not deny coverage or impose cost sharing because a contraceptive was prescribed for a reason other than avoiding pregnancy. ORS 743A.067(5) prohibits treating medications, devices, or products prescribed for non-contraceptive medical indications differently; plans must cover such contraceptives without imposing additional cost sharing or restrictions based on the indication for which the provider prescribed them.
A carrier may deny coverage only for the limited reasons set out in ORS 743A.067(7). Permissible bases for denial include services that are experimental or investigational, part of a clinical trial or demonstration project (subject to statutory exceptions), not consistent with acceptable medical practice, or lacking sufficient evidence of efficacy. Denials on these grounds should be supported by documentation explaining why the criterion applies to the specific claim.
Carriers must not apply utilization controls that effectively prevent continuous use of prescribed contraception or that ignore a provider's determination that a covered therapeutic equivalent is medically inadvisable. Examples of prohibited practices include denying a refill in a way that stops continuous use (the division presumes compliance when carriers allow refills at a 50% or lower remaining-usage threshold) and refusing to cover a prescribed therapeutic equivalent after a provider notifies the plan that the covered equivalent is medically inadvisable. Plans are also expected to cover the full amount prescribed (for example, a 12‑month supply) when required by statute.
Coding and Screening Details
| No codes listed |
Provider Actions, Notification & Utilization Management
No prior authorization for contraception
Health benefit plans may not require prior authorization, step therapy, or other utilization review techniques for medically appropriate covered contraceptive drugs, devices, or products; plans must provide coverage for FDA‑approved contraceptives without prior authorization when no therapeutic equivalent exists.
Prohibition on prior authorization for contraceptives
A carrier may not require prior authorization, step therapy, or other utilization review for medically appropriate covered contraceptive drugs, devices, or products; requiring an exemption request before covering an FDA‑approved contraceptive with no therapeutic equivalent would constitute prohibited prior authorization.
PROHIBITED UTILIZATION REVIEW
Step therapy and other utilization review techniques are prohibited for medically appropriate covered contraceptives; plans must not require stepwise failure prior to coverage of an FDA‑approved contraceptive.
Prohibition on step therapy
ORS 743A.067(2)(j)(D) prohibits health benefit plans from requiring prior authorization, step therapy, or other utilization review techniques for medically appropriate covered contraceptive drugs, devices, or products.
Document and justify denials under ORS 743A.067(7)
When denying a RHEA‑listed service for a reason allowed under ORS 743A.067(7), the carrier must document the reason for the denial and be able to demonstrate why it was appropriate to apply that criterion to the particular claim.
- Provide the enrollee with all appeal rights required under ORS 743B.250.
Provider notification process for medically inadvisable contraceptives
Carriers must establish and maintain an easily accessible, transparent, and sufficiently expedient process by which a health care provider may notify the carrier that a covered therapeutic equivalent is medically inadvisable for a particular enrollee and obtain coverage for the prescribed alternative.
- Process must operate within a timeframe and manner that accounts for medical exigencies.
- If treated as an exceptions process, it must not be unduly burdensome on enrollees or providers.
Permissible denial reasons under ORS 743A.067(7)
A carrier may deny coverage for RHEA services only for reasons listed in ORS 743A.067(7) (e.g., experimental or investigational treatments, clinical trials except as provided, nonconforming to accepted medical practice, insufficient medical evidence, or abortion if the carrier is exempt).
- Carriers must document rationale and provide required appeal rights when denying for these reasons.
Denial triggers: refill thresholds and refusal of prescribed alternatives
Denials based on 'refill too soon' policies that prevent continuous use of a prescribed contraceptive, or denials that refuse coverage for a prescribed therapeutic equivalent after a provider notifies the plan, are inconsistent with RHEA and may lead to enforcement action.
- Example: Failing to cover a 12‑month supply prescribed by a provider is impermissible.
- Example: Refusing a brand prescription after provider notification that a generic is medically inadvisable is impermissible.
Key Definitions
Background and Scope
RHEA requires health benefit plans to cover, without cost sharing, the services listed in ORS 743A.067(2). This coverage obligation overlaps with—but in some respects is broader than—federal preventive service mandates (such as USPSTF and HRSA recommendations) because RHEA’s protections apply regardless of an enrollee’s sex or gender and extend to the range of services, drugs, devices, products, and procedures enumerated in the statute. While plans may use reasonable medical management for services other than contraception and abortion, such management must not undermine RHEA’s requirement for coverage without cost sharing of the services described in ORS 743A.067(2).
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