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7 LONG TITLE
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
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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.
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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[
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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% by July 1, 2017;
131 (B) 65% by July 1, 2018; and
132 (C) 75% 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:
136 (i) health care provider compliance with the psychotropic drug preferred drug list is not
137 at least 75%; or
138 (ii) the department has not realized its projected savings from implementing the
139 preferred drug list for psychotropic drugs.
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141 Committee and to the Social Services Appropriations Subcommittee [
142 November 1, [
143 (a) the savings to the Medicaid program resulting from the use of the preferred drug list
144 permitted by Subsection (1)[
145 (b) the compliance with and savings from the use of the preferred drug list for
146 psychotropic drugs under Subsection (3).
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.