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Third Substitute S.B. 137

Senator Allen M. Christensen proposes the following substitute bill:




Chief Sponsor: Allen M. Christensen

House Sponsor: ____________

             7      LONG TITLE
             8      General Description:
             9          This bill amends the Medicaid drug program.
             10      Highlighted Provisions:
             11          This bill:
             12          .    amends the Medicaid drug program to remove restrictions on the preferred drug list
             13      program;
             14          .    requires the department to authorize a nonpreferred immunosuppressant and
             15      psychotropic drug when the patient is stabilized;
             16          .    requires a report from the Department of Health regarding cost savings to the
             17      Medicaid drug program from the use of a preferred drug list.
             18      Money Appropriated in this Bill:
             19          This bill appropriates:
             20          .    as an ongoing appropriation subject to future budget constraints for fiscal years
             21      2012 forward, $615,000 from the General Fund to the Department of Human
             22      Services - Mental Health Services, with the exception that for fiscal year 2011-12
             23      there is a one-time appropriation of $105,300 from the General Fund to the
             24      Department of Human Services - Mental Health Services; and
             25          .    as an ongoing appropriation subject to future budget constraints for fiscal years

             26      2012 forward, $200,000 from the General Fund to the Department of Health - Medicaid
             27      Optional Services - Dental Services, with the exception that for fiscal year 2011-12 there is no
             28      appropriation to the Department of Health-Medicaid Optional Services - Dental Services.
             29      Other Special Clauses:
             30          None
             31      Utah Code Sections Affected:
             32      AMENDS:
             33          26-18-2.4, as last amended by Laws of Utah 2009, Chapter 324
             35      Be it enacted by the Legislature of the state of Utah:
             36          Section 1. Section 26-18-2.4 is amended to read:
             37           26-18-2.4. Medicaid drug program -- Preferred drug list.
             38          (1) A Medicaid drug program developed by the department under Subsection 26-18-2.3
             39      (2)(f):
             40          (a) shall, notwithstanding Subsection 26-18-2.3 (1)(b), be based on clinical and
             41      cost-related factors which include medical necessity as determined by a provider in accordance
             42      with administrative rules established by the Drug Utilization Review Board;
             43          (b) may include therapeutic categories of drugs that may be exempted from the drug
             44      program;
             45          (c) may include placing some drugs[, except the drugs described in Subsection (2),] on
             46      a preferred drug list to the extent determined appropriate by the department;
             47          (d) notwithstanding the requirements of Part 2, Drug Utilization Review Board, shall
             48      immediately implement the prior authorization requirements for a non-preferred drug that is in
             49      the same therapeutic class as a drug that is:
             50          (i) on the preferred drug list on the date that this act takes effect; or
             51          (ii) added to the preferred drug list after this act takes effect; and
             52          (e) except as prohibited by Subsections 58-17b-606 (4) and (5), the prior authorization
             53      requirements established under Subsections (1)(c) and (d) shall permit a health care provider or
             54      the health care provider's agent to obtain a prior authorization override of the preferred drug list
             55      through the department's pharmacy prior authorization review process, which shall:
             56          (i) provide either telephone or fax approval or denial of the request within 24 hours of

             57      the receipt of a request that is submitted during normal business hours of Monday through
             58      Friday from 8 a.m. to 5 p.m.;
             59          (ii) provide for the dispensing of a limited supply of a requested drug as determined
             60      appropriate by the department in an emergency situation, if the request for an override is
             61      received outside of the department's normal business hours; and
             62          (iii) require the health care provider to provide the department with documentation of
             63      the medical need for the preferred drug list override in accordance with criteria established by
             64      the department in consultation with the Pharmacy and Therapeutics Committee.
             65          (2) (a) For purposes of this Subsection (2)[,]:
             66          (i) "Immunosuppressive drug":
             67          [(i)] (A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
             68      activity of the immune system to aid the body in preventing the rejection of transplanted organs
             69      and tissue; and
             70          [(ii)] (B) does not include drugs used for the treatment of autoimmune disease or
             71      diseases that are most likely of autoimmune origin.
             72          [(b) A preferred drug list developed under the provisions of this section may not
             73      include:(i) a psychotropic or anti-psychotic drug; or (ii) an immunosuppressive drug.]
             74          [(c) The state Medicaid program shall reimburse for a prescription for an
             75      immunosuppressive drug as written by the health care provider for a patient who has undergone
             76      an organ transplant. For purposes of Subsection 58-17b-606 (4), and with respect to patients
             77      who have undergone an organ transplant, the prescription for a particular immunosuppressive
             78      drug as written by a health care provider meets the criteria of demonstrating to the Department
             79      of Health a medical necessity for dispensing the prescribed immunosuppressive drug.]
             80          [(d) Notwithstanding the requirements of Part 2, Drug Utilization Review Board, the
             81      state Medicaid drug program may not require the use of step therapy for immunosuppressive
             82      drugs without the written or oral consent of the health care provider and the patient.]
             83          (ii) "Psychotropic drug" means the following classes of drugs: atypical anti-psychotic,
             84      anti-depressants, anti-convulsant/mood stabilizer, anti-anxiety, Attention Deficit Hyperactivity
             85      Disorder stimulants, or sedative/hypnotics.
             86          (iii) "Stabilized" means a health care provider has documented in the patient's medical
             87      chart that a patient has achieved a stable or steadfast medical state within the past 180 days

             88      using a particular psychotropic drug.
             89          (b) The department shall grant a prior authorization for a psychotropic drug or an
             90      immunosuppresive drug that is not on the preferred drug list for a patient who is stabilized on
             91      the drug.
             92          (c) A prior authorization granted under Subsection (2)(b) is valid for one year from the
             93      date the department grants the prior authorization and shall be renewed in accordance with
             94      Subsection (2)(b).
             95          (3) The department shall report to the Health and Human Services Interim Committee
             96      and to the Health and Human Services Appropriations Subcommittee prior to November 1,
             97      [2010] 2013, regarding the savings to the Medicaid program resulting from the use of the
             98      preferred drug list permitted by Subsection (1).
             99          Section 2. Appropriation.
             100          (1) Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures Act,
             101      the following sums of money are appropriated from resources not otherwise appropriated out of
             102      the funds or accounts indicated for the fiscal year beginning July 1, 2011, and ending June 30,
             103      2012. These are additions to amounts previously appropriated for fiscal year 2011-12.
             104           Item 1 To Department of Human Services - Division of Substance Abuse and Mental Health
             105              From General Fund                             $615,000
             106              From General Fund, one-time                    ($509,700)
             107              Schedule of Programs:        
             108                  Mental Health Centers            $105,300
             109          Item 2 To Department of Health - Medicaid Optional Services
             110              From General Fund                             $200,000
             111              From General Fund, one-time                    ($200,000)
             112              Schedule of Programs:
             113                  Dental Services                 -0-
             114          (2) The Legislature intends that the ongoing money appropriated for dental services in
             115      this bill be used to restore emergency dental services.

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