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          ▸     authorizes the Department of Health to include all psychotropic and anti-psychotic
14     drugs on the Medicaid program's preferred drug list;
15          ▸     amends prior authorization provisions for the preferred drug list to address
16     psychotropic and anti-psychotic drugs; and
17          ▸     requires the department to report on savings resulting from the preferred drug list.
18     Money Appropriated in this Bill:
19          None
20     Other Special Clauses:
21          None
22     Utah Code Sections Affected:
23     AMENDS:
24          26-18-2.4, as last amended by Laws of Utah 2012, Chapters 242 and 343

26     Be it enacted by the Legislature of the state of Utah:
27          Section 1. Section 26-18-2.4 is amended to read:

28          26-18-2.4. Medicaid drug program -- Preferred drug list.
29          (1) A Medicaid drug program developed by the department under Subsection
30     26-18-2.3(2)(f):
31          (a) shall, notwithstanding Subsection 26-18-2.3(1)(b), be based on clinical and
32     cost-related factors which include medical necessity as determined by a provider in accordance
33     with administrative rules established by the Drug Utilization Review Board;
34          (b) may include therapeutic categories of drugs that may be exempted from the drug
35     program;
36          (c) may include placing some drugs, except the drugs described in Subsection (2), on a
37     preferred drug list to the extent determined appropriate by the department;
38          (d) notwithstanding the requirements of Part 2, Drug Utilization Review Board, shall
39     immediately implement the prior authorization requirements for a nonpreferred drug that is in
40     the same therapeutic class as a drug that is:
41          (i) on the preferred drug list on the date that this act takes effect; or
42          (ii) added to the preferred drug list after this act takes effect; and
43          (e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior
44     authorization requirements established under Subsections (1)(c) and (d) which shall permit a
45     health care provider or the health care provider's agent to obtain a prior authorization override
46     of the preferred drug list through the department's pharmacy prior authorization review process,
47     and which shall:
48          (i) provide either telephone or fax approval or denial of the request within 24 hours of
49     the receipt of a request that is submitted during normal business hours of Monday through
50     Friday from 8 a.m. to 5 p.m.;
51          (ii) provide for the dispensing of a limited supply of a requested drug as determined
52     appropriate by the department in an emergency situation, if the request for an override is
53     received outside of the department's normal business hours; and
54          (iii) require the health care provider to provide the department with documentation of
55     the medical need for the preferred drug list override in accordance with criteria established by
56     the department in consultation with the Pharmacy and Therapeutics Committee.
57          (2) (a) For purposes of this Subsection (2):
58          (i) "Immunosuppressive drug":

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

90     discontinuation;
91          (ii) detailed evidence of a potential drug interaction between current medication and
92     the preferred drug;
93          (iii) detailed evidence of a condition or contraindication that prevents the use of the
94     preferred drug;
95          (iv) objective clinical evidence that a patient is at high risk of adverse events due to a
96     therapeutic interchange with a preferred drug;
97          (v) the patient is a new or previous Medicaid client with an existing diagnosis
98     previously stabilized with a nonpreferred drug; or
99          (vi) other valid reasons as determined by the department.
100          [(g)] (f) A prior authorization granted under Subsection (2)[(f)](e) is valid for one year
101     from the date the department grants the prior authorization and shall be renewed in accordance
102     with Subsection (2)[(f)](e).
103          (3) The department shall report to the Health and Human Services Interim Committee
104     and to the Social Services Appropriations Subcommittee prior to November 1, [2013] 2015,
105     regarding the savings to the Medicaid program resulting from the use of the preferred drug list
106     permitted by Subsection (1).

Legislative Review Note
     as of 1-12-15 9:04 AM

Office of Legislative Research and General Counsel