Assigned to HHS FOR COMMITTEE
ARIZONA STATE SENATE
Fifty-Seventh Legislature, First Regular Session
FACT SHEET FOR S.B. 1720
clozapine; access; treatment protocols
Purpose
Requires a health insurer, the Arizona Health care Cost Containment System (AHCCCS)
and contractors with AHCCCS to provide reimbursement for treatment and services that are unique
to members and subscribers who are prescribed clozapine. Outlines treatment protocols and
covered services for members and subscribers who are prescribed clozapine and adds the
prescribed treatment protocols and services to the services provided by the Arizona Long Term
Care System (ALTCS) and the comprehensive behavioral health service system for children
implemented by AHCCCS.
Background
AHCCCS contracts with health professionals to provide medically necessary health and
medical services to eligible members. AHCCCS contractors are required to provide services and
supplies including but not limited to:1) inpatient and outpatient hospital services; 2) laboratory and
X-ray services; 3) prescription medications; 4) medical supplies, durable medical equipment,
insulin pumps and prosthetic devices, excluding cochlear implants; 5) treatment of medical
conditions of the eye; 6) early and periodic health screening and diagnostic services; 7) family
planning services; 8) podiatry services; 9) nonexperimental transplants; 10) emergency dental care;
11) ambulance and nonambulance transportation; 12) hospice care; 13) orthotics; and 14) diabetes
outpatient self-management training services (A.R.S. § 36-2907).
ALTCS is the management and delivery system of hospitalization, medical care,
institutional services and home and community-based services to members through AHCCCS,
program contractors and providers, together with federal participation under Title XIX of the
Social Security Act. ALTCS program contractors must provide certain services to ALTCS
members who are determined to need institutional services, including: 1) nursing facility services,
other than services in an institution for tuberculosis or mental disease; 2) behavioral health services
that are not duplicative of prescribed long-term care services and that are authorized by the
program contractor through the long-term care case management system; 3) hospice services;
4) case management services; 5) health and medical services covered by AHCCCS; and 6) dental
services (A.R.S. §§ 36-2932 and 36-2939).
Clozapine is used to treat severely ill patients with schizophrenia who have used other
medicines that did not work well and to lower the risk of suicidal behavior in patients with
schizophrenia or schizoaffective disorder. Clozapine changes some of the chemicals in the brain
that are thought to cause schizophrenia. Clozapine may cause serious blood problems that a patient
will not be able to feel. A doctor will check the patient's blood at regular visits and it is important
that the patient have blood tests done when scheduled. The pharmacy will give a patient clozapine
only if the patient's blood tests show that it is safe for the patient to take, as clozapine can FACT SHEET
S.B. 1720
Page 2
temporarily lower the number of white blood cells in a person's blood, increasing the chance of
getting an infection (Mayo Clinic).
If there is an increased cost to AHCCCS associated with providing reimbursement for
outlined treatment and services that are unique to AHCCCS members who are prescribed
clozapine, there may be a fiscal impact to the state General Fund.
Provisions
Health Insurer Subscriber Clozapine Access and Treatment Protocol
1. Requires a health insurer to provide reimbursement for treatment and services that are unique
to subscribers who are prescribed clozapine.
2. Allows all psychiatric examinations of subscribers who are prescribed clozapine to be billed
at the highest level of complexity.
3. Prohibits a health insurer from restricting the number or frequency of psychiatric visits for
subscribers who are prescribed clozapine.
4. Requires psychiatric examinations, during the first 12 months that a subscriber receives
clozapine treatment, to be reimbursed with an enhanced case rate that includes an additional
30 percent above the high complexity visit to compensate for administrative tasks and care
management associated with additional laboratory testing and patient monitoring.
5. Requires medical weight management to be provided to treat and prevent clozapine-induced
weight gain and other metabolic disorders associated with clozapine treatment.
6. Stipulates that for refractory excessive salivation that does not respond to topical or oral
treatments specialty treatments, such as botulinum toxin injections, must be provided and, if
necessary, include administration by a trained specialist and all necessary office visits.
7. Specifies that a subscriber who is prescribed clozapine must have access to less-invasive means
of hematological monitoring, such as finger-stick absolute neutrophil count devices, as
prescribed.
8. Requires outlined supplies and services to be provided to a subscriber who receives clozapine
treatment, including:
a) clinical assistance and supplies associated with the administration of finger-stick patient
monitoring;
b) mobile phlebotomy services, if requested by the subscriber or the subscriber's guardian, for
necessary hematological testing; and
c) genetic testing, as necessary, to identify genes associated with benign ethnic neutropenia
and genes linked to increased risk of clozapine-induced neutropenia and to guide
hematological monitoring frequency and neutrophil parameters.
9. Requires prescription drug coverage to include clozapine for emergency use outside of the
standard refill utilization requirements, if requested by the subscriber or the subscriber's
guardian. FACT SHEET
S.B. 1720
Page 3
10. Directs a health insurer to establish criteria to proactively identify participating providers that
may be underutilizing clozapine, including prescribers who treat subscribers with schizophrenia
or schizoaffective disorder without prescribing clozapine.
11. Requires participating providers who demonstrate poor clozapine utilization to be notified at
least every quarter.
12. Requires the health insurer to offer clozapine-specific training as prescribed for all
participating providers who provide behavioral health treatment.
13. Specifies that, in the delivery of care and services for subscribers with a serious mental illness
or serious emotional disturbance designation, the health insurer must:
a) offer in-home hematological monitoring, as outlined;
b) cover medication delivery or mail order medication services if the participating provider
determines the service and delivery conditions are appropriate for the subscriber; and
c) provide a level of support services that accommodates additional medication assistance to
ensure a subscriber's adherence and consistency, as outlined.
14. Requires outlined support services to be provided to a subscriber who is being discharged from
an inpatient facility, behavioral health residential facility or any 24-hour supervised program.
15. Instructs participating providers that are inpatient behavioral health facilities with a pharmacy
and that serve subscribers with psychiatric needs to maintain clozapine in stock.
AHCCCS Member Clozapine Access and Treatment Protocol
16. Requires AHCCCS and contractors with AHCCCS to provide members who are prescribed
clozapine with reimbursement for treatment and services, and to follow all related treatment
protocols as outlined for subscribers through a health insurer.
17. Specifies that in the delivery of care and services for members with a serious mental illness or
emotional disturbance designation, in addition to the treatment protocols prescribed for
subscribers through a health insurer, AHCCCS and contracted regional behavioral health
authorities with AHCCCS must:
a) offer single-case agreements for non-title XIV members to receive services from private
out-of-network providers who prescribe clozapine when medically necessary or to promote
timely access to care, if the prescriber is licensed in Arizona and is registered with
AHCCCS; and
b) designate all members who are prescribed clozapine as a special assistance member, unless
the designation is declined by the member or the member's guardian.
18. Adds clozapine access and treatment protocols as prescribed for members of AHCCCS to the
services required to be provided under ALTCS.
19. Adds clozapine access and treatment protocols, as outlined for members of AHCCCS, to
services included under the comprehensive behavioral health service system for children
implemented by AHCCCS.
FACT SHEET
S.B. 1720
Page 4
Miscellaneous
20. Requires a county jail, the Arizona Department of Corrections Rehabilitation and Reentry
(ADCRR) and private prison providers contracted with ADCRR to provide an inmate who is
prescribed clozapine with access to clozapine and the related treatment protocols as outlined
for subscribers through a health insurer.
21. Defines terms.
22. Makes technical and conforming changes.
23. Becomes effective on the general effective date.
Prepared by Senate Research
February 17, 2025
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