HLS 13RS-973 REENGROSSED
Page 1 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
Regular Session, 2013
HOUSE BILL NO. 393
BY REPRESENTATIVES ANDERS AND STUART BISHOP
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
MEDICAID: Provides relative to prescription drug benefits of certain managed care
organizations participating in the La. Medicaid coordinated care network program
AN ACT1
To enact Part XI of Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950, to be2
comprised of R.S. 46:460.31 through 460.35, relative to the medical assistance3
program; to provide relative to managed care organizations which provide health4
care services to medical assistance program enrollees; to provide relative to5
prescription drugs; to provide for prepaid coordinated care network pharmaceutical6
and therapeutics committees; to provide for a standard form for the prior7
authorization of prescription drugs; to provide for certain procedures relative to step8
therapy and fail first protocols; to provide for promulgation of rules; to provide for9
exemptions; and to provide for related matters.10
Be it enacted by the Legislature of Louisiana:11
Section 1. Part XI of Chapter 3 of Title 46 of the Louisiana Revised Statutes of 1950,12
comprised of R.S. 46:460.31 through 460.35, is hereby enacted to read as follows:13
PART XI. MEDICAID MANAGED CARE PRESCRIPTION DRUG BENEFITS14
§460.31. Definitions15
As used in this Part, the following terms shall have the meaning ascribed to16
them in this Section unless the context clearly indicates otherwise:17
(1) "Department" means the Department of Health and Hospitals.18
(2) "Managed care organization" shall have the same meaning as provided19
for that term in 42 CFR 438.2 and shall also mean any entity providing primary care20 HLS 13RS-973 REENGROSSED
HB NO. 393
Page 2 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
case management services to Medicaid recipients pursuant to a contract with the1
department.2
(3) "Medicaid" and "medical assistance program" mean the medical3
assistance program provided for in Title XIX of the Social Security Act.4
(4) "Prepaid coordinated care network" means a private entity that contracts5
with the department to provide Medicaid benefits and services to enrollees of the6
Medicaid coordinated care program known as "Bayou Health" in exchange for a7
monthly prepaid capitated amount per member.8
(5) "Primary care case management" means a system in which an entity9
contracts with the state to furnish case management services, which include but are10
not limited to the location, coordination, and monitoring of primary health care11
service to Medicaid beneficiaries.12
(6) "Secretary" means the secretary of the Department of Health and13
Hospitals.14
§460.32. Prepaid coordinated care networks; pharmaceutical and therapeutics15
committees16
On or before January 1, 2014, each prepaid coordinated care network shall17
form a body to be designated as a "Pharmaceutical and Therapeutics Committee"18
which shall develop a drug formulary and preferred drug list for the prepaid19
coordinated care network. Each Pharmaceutical and Therapeutics Committee20
created pursuant to the provisions of this Section shall meet no less frequently than21
semiannually in Baton Rouge, Louisiana. Such meetings shall be open to the public22
and shall allow for public comment prior to voting by the committee on any change23
in the preferred drug list or formulary.24
§460.33. Prior authorization form; requirements25
A. Beginning January 1, 2014, all managed care organizations shall utilize26
a two-page prior authorization form, excluding guidelines or information, duly27
promulgated by the department in accordance with the Administrative Procedure28
Act.29 HLS 13RS-973 REENGROSSED
HB NO. 393
Page 3 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
B. The department shall promulgate rules and regulations prior to January1
1, 2014, that establish the form which shall be utilized by all managed care2
organizations. The department may consult with the managed care organizations as3
necessary in development of the prior authorization form.4
§460.34. Step therapy; fail first protocols; requirements5
A. Each managed care organization that utilizes step therapy or fail first6
protocols shall comply with the provisions of this Section.7
B. When medications for the treatment of any medical condition are8
restricted for use by a managed care organization by a step therapy or fail first9
protocol, the prescribing physician shall be provided with and have access to a clear10
and convenient process to expeditiously request an override of such restriction from11
the managed care organization. The managed care organization shall expeditiously12
grant an override of such restriction under any of the following circumstances:13
(1) The prescribing physician can demonstrate to the managed care14
organization, based on sound clinical evidence, that the preferred treatment required15
under step therapy or fail first protocol has been ineffective in the treatment of the16
Medicaid enrollee's disease or medical condition.17
(2) The prescribing physician can demonstrate to the managed care18
organization, based on sound clinical evidence, that the preferred treatment required19
under the step therapy or fail first protocol is reasonably expected to be ineffective20
based on the known relevant physical or mental characteristics and medical history21
of the Medicaid enrollee and known characteristics of the drug regimen.22
(3) The prescribing physician can demonstrate to the managed care23
organization, based on sound clinical evidence, that the preferred treatment required24
under the step therapy or fail first protocol will cause or will likely cause an adverse25
reaction or other physical harm to the Medicaid enrollee.26
C. The duration of any step therapy or fail first protocol shall not be longer27
in duration than the customary period for the medication when such treatment is28
demonstrated by the prescribing physician to be clinically ineffective. When the29
managed care organization can demonstrate, through sound clinical evidence, that30 HLS 13RS-973 REENGROSSED
HB NO. 393
Page 4 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
the originally prescribed medication is likely to require more than the customary1
period for such medication to provide any relief or an amelioration to the Medicaid2
enrollee, the step therapy or fail first protocol may be extended for an additional3
period of time no longer than the original customary period for the medication.4
§460.35. Exemptions5
The provisions of this Part shall not apply to any entity that contracts with the6
department to provide fiscal intermediary services in processing claims of health care7
providers.8
Section 2. This Act shall become effective on January 1, 2014.9
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Anders HB No. 393
Abstract: Provides relative to prescription drug benefits of managed care organizations
participating in the La. Medicaid coordinated care network program.
Proposed law defines "prepaid coordinated care network" as a private entity that contracts
with the department to provide Medicaid benefits and services to enrollees of the Medicaid
coordinated care program known as "Bayou Health" in exchange for a monthly prepaid
capitated amount per member.
Proposed law requires each prepaid coordinated care network to form a pharmaceutical and
therapeutics committee which shall develop a drug formulary and preferred drug list for the
prepaid coordinated care network. Provides that such committees shall:
(1)Meet no less frequently than semiannually in Baton Rouge.
(2)Make such meetings open to the public.
(3)Allow for public comment at such meetings prior to voting by the committee on any
change in the preferred drug list or formulary.
Proposed law requires, beginning Jan. 1, 2014, that all managed care organizations
participating in the La. Medicaid program utilize a two-page prior authorization form to be
issued by DHH. Requires DHH to promulgate rules and regulations that establish the form,
and authorizes DHH to consult with the managed care organizations as necessary in
development of the form.
Proposed law requires that each managed care organization which utilizes step therapy or
fail first protocols comply with the provisions of proposed law.
Proposed law provides that when medications are restricted for use by a managed care
organization by a step therapy or fail first protocol, the prescribing physician shall be
provided with and have access to a clear and convenient process to expeditiously request an HLS 13RS-973 REENGROSSED
HB NO. 393
Page 5 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
override of such restriction from the managed care organization. Requires the managed care
organization to expeditiously grant an override of such restriction under any of the following
circumstances:
(1)The prescribing physician can demonstrate to the managed care organization, based
on sound clinical evidence, that the preferred treatment required under step therapy
or fail first protocol has been ineffective in the treatment of the Medicaid enrollee's
disease or medical condition.
(2)The prescribing physician can demonstrate to the managed care organization, based
on sound clinical evidence, that the preferred treatment required under the step
therapy or fail first protocol is reasonably expected to be ineffective based on the
known relevant physical or mental characteristics and medical history of the
Medicaid enrollee and known characteristics of the drug regimen.
(3)The prescribing physician can demonstrate to the managed care organization, based
on sound clinical evidence, that the preferred treatment required under the step
therapy or fail first protocol will cause or will likely cause an adverse reaction or
other physical harm to the Medicaid enrollee.
Proposed law provides that the duration of any step therapy or fail first protocol shall not be
longer in duration than the customary period for the medication when such treatment is
demonstrated by the prescribing physician to be clinically ineffective. Provides that when
the managed care organization can demonstrate, through sound clinical evidence, that the
originally prescribed medication is likely to require more than the customary period for such
medication to provide any relief or an amelioration to the Medicaid enrollee, the step therapy
or fail first protocol may be extended for an additional period of time no longer than the
original customary period for the medication.
Proposed law provides that provisions of proposed law shall not apply to any entity that
contracts with DHH to provide fiscal intermediary services in processing claims of health
care providers.
Effective Jan. 1, 2014.
(Adds R.S. 46:460.31-460.35)
Summary of Amendments Adopted by House
Committee Amendments Proposed by House Committee on Health and Welfare to the
original bill.
1. Deleted provisions creating and specifying functions of a Medicaid Managed
Care Pharmaceutical and Therapeutics Committee.
2. Deleted requirement that all managed care organizations provide as a pharmacy
benefit the minimum drug pharmacopoeia in conjunction with a prior approval
process developed and maintained by the Medicaid Managed Care
Pharmaceutical and Therapeutics Committee.
3. Added "prepaid coordinated care network" as a defined term, defining such term
as a private entity that contracts with the department to provide Medicaid
benefits and services to enrollees of the Medicaid coordinated care program
known as "Bayou Health" in exchange for a monthly prepaid capitated amount
per member.
4. Added provisions requiring each prepaid coordinated care network to form a
pharmaceutical and therapeutics committee which shall develop a drug formulary HLS 13RS-973 REENGROSSED
HB NO. 393
Page 6 of 6
CODING: Words in struck through type are deletions from existing law; words underscored
are additions.
and preferred drug list for the prepaid coordinated care network. Provided that
such committees are subject to the following requirements:
(a)Meet no less frequently than semiannually in Baton Rouge.
(b)Make such meetings open to the public.
(c)Allow for public comment at such meetings prior to voting by the
committee on any change in the preferred drug list or formulary.
5. Changed prescribed page length for the prior authorization form provided for in
proposed law from one page to two pages.
6. Added an exemption from provisions of proposed law for any entity that
contracts with DHH to provide fiscal intermediary services in processing claims
of health care providers.
7. Changed effective date of proposed law from date of signature by the governor
or lapse of time for gubernatorial action to Jan. 1, 2014.
8. Made technical changes.
House Floor Amendments to the engrossed bill.
1. Made technical change.