This document includes House Floor Amendments incorporated into the bill on Fri, Feb 26, 2016 at 4:14 PM by lsjones.
Representative Paul Ray proposes the following substitute bill:




Chief Sponsor: Raymond P. Ward

Senate Sponsor: Allen M. Christensen


8     General Description:
9          This bill authorizes the Department of Health to include additional drugs on the
10     Medicaid program's preferred drug list.
11     Highlighted Provisions:
12          This bill:
13          ▸     amends definitions;
14          ▸     authorizes the Department of Health to include psychotropic drugs on the Medicaid
15     program's preferred drug list;
16          ▸     creates the Medicaid Preferred Drug List Restricted Account;
17          ▸     requires 40% of the savings attributable to this bill to be deposited into the account;
18          ▸     limits use of the account to appropriations to the Department of Human Services;
19     and
20          ▸     makes technical amendments.
21     Money Appropriated in this Bill:
22          None
23     Other Special Clauses:
24          None
25     Utah Code Sections Affected:

26     AMENDS:
27          26-18-2.4, as last amended by Laws of Utah 2012, Chapters 242 and 343

29     Be it enacted by the Legislature of the state of Utah:
30          Section 1. Section 26-18-2.4 is amended to read:
31          26-18-2.4. Medicaid drug program -- Preferred drug list.
32          (1) A Medicaid drug program developed by the department under Subsection
33     26-18-2.3(2)(f):
34          (a) shall, notwithstanding Subsection 26-18-2.3(1)(b), be based on clinical and
35     cost-related factors which include medical necessity as determined by a provider in accordance
36     with administrative rules established by the Drug Utilization Review Board;
37          (b) may include therapeutic categories of drugs that may be exempted from the drug
38     program;
39          (c) may include placing some drugs, except the drugs described in Subsection (2), on a
40     preferred drug list:
41          (i) to the extent determined appropriate by the department; and
42          (ii) in the manner described in Subsection (3) for psychotropic drugs;
43          (d) notwithstanding the requirements of Part 2, Drug Utilization Review Board, and
44     except as provided in Subsection (3), shall immediately implement the prior authorization
45     requirements for a nonpreferred drug that is in the same therapeutic class as a drug that is:
46          (i) on the preferred drug list on the date that this act takes effect; or
47          (ii) added to the preferred drug list after this act takes effect; and
48          (e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior
49     authorization requirements established under Subsections (1)(c) and (d) which shall permit a
50     health care provider or the health care provider's agent to obtain a prior authorization override
51     of the preferred drug list through the department's pharmacy prior authorization review process,
52     and which shall:
53          (i) provide either telephone or fax approval or denial of the request within 24 hours of
54     the receipt of a request that is submitted during normal business hours of Monday through
55     Friday from 8 a.m. to 5 p.m.;
56          (ii) provide for the dispensing of a limited supply of a requested drug as determined

57     appropriate by the department in an emergency situation, if the request for an override is
58     received outside of the department's normal business hours; and
59          (iii) require the health care provider to provide the department with documentation of
60     the medical need for the preferred drug list override in accordance with criteria established by
61     the department in consultation with the Pharmacy and Therapeutics Committee.
62          (2) (a) For purposes of this Subsection (2):
63          (i) "Immunosuppressive drug":
64          (A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
65     activity of the immune system to aid the body in preventing the rejection of transplanted organs
66     and tissue; and
67          (B) does not include drugs used for the treatment of autoimmune disease or diseases
68     that are most likely of autoimmune origin.
69          [(ii) "Psychotropic drug" means the following classes of drugs: atypical anti-psychotic,
70     anti-depressants, anti-convulsant/mood stabilizer, anti-anxiety, attention deficit hyperactivity
71     disorder stimulants, or sedative/hypnotics.]
72          [(iii)] (ii) "Stabilized" means a health care provider has documented in the patient's
73     medical chart that a patient has achieved a stable or steadfast medical state within the past 90
74     days using a particular psychotropic drug.
75          (b) A preferred drug list developed under the provisions of this section may not
76     include[: (i) except as provided in Subsection (2)(e), a psychotropic or anti-psychotic drug; or
77     (ii)] an immunosuppressive drug.
78          (c) The state Medicaid program shall reimburse for a prescription for an
79     immunosuppressive drug as written by the health care provider for a patient who has undergone
80     an organ transplant. For purposes of Subsection 58-17b-606(4), and with respect to patients
81     who have undergone an organ transplant, the prescription for a particular immunosuppressive
82     drug as written by a health care provider meets the criteria of demonstrating to the Department
83     of Health a medical necessity for dispensing the prescribed immunosuppressive drug.
84          (d) Notwithstanding the requirements of Part 2, Drug Utilization Review Board, the
85     state Medicaid drug program may not require the use of step therapy for immunosuppressive
86     drugs without the written or oral consent of the health care provider and the patient.
87          (e) The department may include a sedative hypnotic on a preferred drug list in

88     accordance with Subsection (2)(f).
89          (f) The department shall grant a prior authorization for a sedative hypnotic that is not
90     on the preferred drug list under Subsection (2)(e), if the health care provider has documentation
91     related to one of the following conditions for the Medicaid client:
92          (i) a trial and failure of at least one preferred agent in the drug class, including the
93     name of the preferred drug that was tried, the length of therapy, and the reason for the
94     discontinuation;
95          (ii) detailed evidence of a potential drug interaction between current medication and
96     the preferred drug;
97          (iii) detailed evidence of a condition or contraindication that prevents the use of the
98     preferred drug;
99          (iv) objective clinical evidence that a patient is at high risk of adverse events due to a
100     therapeutic interchange with a preferred drug;
101          (v) the patient is a new or previous Medicaid client with an existing diagnosis
102     previously stabilized with a nonpreferred drug; or
103          (vi) other valid reasons as determined by the department.
104          (g) A prior authorization granted under Subsection (2)(f) is valid for one year from the
105     date the department grants the prior authorization and shall be renewed in accordance with
106     Subsection (2)(f).
107          (3) (a) For purposes of this Subsection (3), "psychotropic drug" means the following
108     classes of drugs:
109          (i) atypical anti-psychotic;
110          (ii) anti-depressant;
111          (iv) anti-convulsant/mood stabilizer;
112          (v) anti-anxiety; and
113          (vi) attention deficit hyperactivity disorder stimulant.
114          (b) The department shall, by July 1, 2016, develop a preferred drug list for
115     psychotropic drugs. Except as provided in Subsection (3)(d), a preferred drug list for
116     psychotropic drugs developed under this section shall allow a health care provider to override
117     the preferred drug list by writing "dispense as written" on the prescription for the psychotropic
118     drug. A healthcare provider may not override Section 58-17b-606 by writing "dispense as

119     written" on a prescription.
120          (c) The department, and a Medicaid accountable care organization that is responsible
121     for providing behavioral health, shall:
122          (i) establish a system to:
123          (A) track health care provider prescribing patterns for psychotropic drugs;
124          (B) educate health care providers who are not complying with the preferred drug list;
125     and
126          (C) implement peer to peer education for health care providers whose prescribing
127     practices continue to not comply with the preferred drug list; and
128          (ii) determine whether health care provider compliance with the preferred drug list is at
129     least:
130          (A) 55% Ĥ→ of prescriptions ←Ĥ by July 1, 2017;
131          (B) 65% Ĥ→ of prescriptions ←Ĥ by July 1, 2018; and
132          (C) 75% Ĥ→ of prescriptions ←Ĥ by July 1, 2019.
133          (d) Beginning October 1, 2019, the department shall eliminate the dispense as written
134     override for the preferred drug list, and shall implement a prior authorization system for
135     psychotropic drugs, in accordance with Subsection (2)(f), if by July 1, 2019 Ĥ→ [
136          (i) health care provider compliance with the psychotropic drug preferred drug list is not
137     at least 75%; or
138          (ii)
] , ←Ĥ
the department has not realized Ĥ→ [its projected] annual ←Ĥ savings
138a     from implementing the
139     preferred drug list for psychotropic drugs Ĥ→ of at least $750,000, in General Fund
139a     savings ←Ĥ .
139b      Ĥ→ (e) The department shall report to the Health and Human Services
139c     Interim Committee and the Social Services Appropriations Subcommittee before
139d     November 30, 2016, and before each November 30 thereafter regarding compliance
139e     with and savings from implementation of Subsection (3). ←Ĥ
140          [(3)] (4) The department shall report to the Health and Human Services Interim
141     Committee and to the Social Services Appropriations Subcommittee [prior to] before
142     November 1, [2013] 2016, and before each November 30 thereafter, regarding Ĥ→ [
143          (a)
] ←Ĥ
the savings to the Medicaid program resulting from the use of the preferred drug list
144     permitted by Subsection (1) Ĥ→ [
[.]; and
145          (b) the compliance with and savings from the use of the preferred drug list for
146     psychotropic drugs under Subsection (3)
] ←Ĥ
147          (5) (a) There is created a restricted account within the General Fund called the
148     "Medicaid Preferred Drug List Restricted Account."
149          (b) The account consists of savings to the Medicaid program attributable to the

150     inclusion of psychotropic drugs on the preferred drug list.
151          (c) Savings to the Medicaid program under Subsection (4)(b) shall be calculated for
152     each fiscal year by the department.
153          (d) For each fiscal year, the Legislature shall appropriate to the account an amount
154     equal to 40% of the savings calculated for the immediately preceding fiscal year, except that
155     appropriations shall be reduced as necessary to ensure that the account's balance does not
156     exceed $2,000,000.
157          (e) Funds from the account may be used only for appropriations by the Legislature to
158     the Department of Human Services.