General Assembly Substitute Bill No. 6545
January Session, 2013 *_____HB06545HS_APP040313____*
General Assembly
Substitute Bill No. 6545
January Session, 2013
*_____HB06545HS_APP040313____*
AN ACT CONCERNING DRUG PRIOR AUTHORIZATION FOR MEDICAID RECIPIENTS.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Section 17b-491a of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2013):
(a) The Commissioner of Social Services may require prior authorization of any prescription for a drug covered under a medical assistance program administered by the Department of Social Services, including an over-the-counter drug. The authorization for a brand name drug product shall be valid for one year from the date the prescription is first filled. The Commissioner of Social Services shall establish a procedure by which prior authorization under this subsection shall be obtained from an independent pharmacy consultant acting on behalf of the Department of Social Services, under an administrative services only contract.
(b) When prior authorization is required for coverage of a prescription drug under a medical assistance program administered by the Department of Social Services and a pharmacist is unable to obtain the prescribing physician's authorization at the time the prescription is presented to be filled, the pharmacist shall dispense a one-time fourteen-day supply. The commissioner shall process a prior authorization request from a physician or pharmacist not later than two hours after the commissioner's receipt of the request. If prior authorization is not granted or denied within two hours of receipt by the commissioner of the request for prior authorization, it shall be deemed granted.
(c) The Commissioner of Social Services, not later than October 1, 2012, shall issue a flier to pharmacies for distribution to Medicaid recipients who receive such one-time prescription supplies in the absence of prior prescription authorization. The flier shall notify recipients that (1) prior authorization is required for the prescription to be fully filled, (2) the fourteen-day supply is a one-time supply, and (3) recipients must contact the prescriber to arrange for prior authorization of a full prescription. The commissioner shall require pharmacists who receive Medicaid reimbursements for prescriptions to provide said flier to such Medicaid recipients and to ensure that Medicaid recipients acknowledge receipt of said flier in writing.
(d) Notwithstanding the provisions of section 17b-262 and any regulation adopted thereunder, on or after July 1, 2000, the Commissioner of Social Services may establish a schedule of maximum quantities of oral dosage units permitted to be dispensed at one time for prescriptions covered under a medical assistance program administered by the Department of Social Services, including prescriptions for over-the-counter drugs, based on a review of utilization patterns.
(e) A schedule established pursuant to subsection (d) of this section and, on and after July 1, 2005, any revisions thereto, shall be submitted to the joint standing committees of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies. [Within] Not later than sixty days [of] after receipt of such a schedule or revisions thereto, said joint standing committees of the General Assembly shall approve or deny the schedule or any revisions thereto and advise the commissioner of their approval or denial of the schedule or any revisions thereto. The schedule or any revisions thereto shall be deemed approved unless all committees vote to reject such schedule or revisions thereto [within] not later than sixty days [of] after receipt of such schedule or revisions thereto.
Sec. 2. (NEW) (Effective July 1, 2013) (a) The Commissioner of Social Services may establish a step therapy program for prescription drugs in the Medicaid program. The commissioner may condition payment for such drugs on a requirement that the drug be prescribed from the preferred drug list established pursuant to section 17b-274d of the general statutes prior to any other drug, provided any step therapy program shall: (1) Require that the patient try and fail on only one medication on the preferred drug list before another drug can be prescribed and eligible for payment; (2) not apply to any mental health–related drugs; (3) not apply to a drug generally prescribed for a condition treated on an ongoing basis, either with continuous medication or a medication taken as needed by a beneficiary who has filled a prescription for the same drug within the preceding one hundred eighty days; and (4) require that the prescribing physician, when medications for the treatment of any medical condition are restricted due to the step therapy program, have access to a clear and convenient process to expeditiously request an override of such restriction from the Department of Social Services. An override of such restriction shall be expeditiously granted whenever the prescribing physician can demonstrate that: (A) The preferred treatment required under step therapy has been ineffective in the treatment of the patient's medical condition in the past; (B) the drug regimen required under the step therapy program is expected to be ineffective based on the known relevant physical or mental characteristics of the patient and the known characteristics of the drug regimen; (C) the preferred treatment required under the step therapy program will cause or will likely cause an adverse reaction or other physical harm to the patient; and (D) it is in the best interest of the patient to provide the recommended therapy or drug based on medical necessity.
(b) The duration of any step therapy program requirement shall not be longer than a period of seven days, after which time the prescribing physician may deem such treatment as clinically ineffective for the patient. When the prescribing physician deems the treatment to be clinically ineffective, the drug prescribed and recommended by the physician shall be dispensed and covered under the Medicaid program.
This act shall take effect as follows and shall amend the following sections:
Section 1 July 1, 2013 17b-491a
Sec. 2 July 1, 2013 New section
This act shall take effect as follows and shall amend the following sections:
Section 1
July 1, 2013
17b-491a
Sec. 2
July 1, 2013
New section
HS Joint Favorable Subst. C/R APP
HS
Joint Favorable Subst. C/R
APP