Adverse determinations to include alternative

prescription drugs — Qualifications of reviewers.

A utilization review entity shall ensure that all adverse

determinations include alternative prescription drugs covered by the

health plan's formulary and are made by a physician, pharmacist, or

licensed mental health professional. The physician, pharmacist, or

licensed mental health professional shall:

1. Possess a current and valid nonrestricted license in any

United States jurisdiction;

2. Have the appropriate training, knowledge, or expertise to

apply appropriate clinical guidelines to the health care service

being requested; and

3. Make the adverse determination under the clinical direction

provided by the committee or board responsible for developing

policies for drug use, evaluating clinical appropriateness, and

ensuring effective drug use when reviewing prescription drug prior

authorizations to enrollees of Oklahoma. All such medical directors

shall be physicians licensed in any United States jurisdiction.