ENROLLED
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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.
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
case management services to Medicaid recipients pursuant to a contract with the21
department.22 ENROLLEDHB NO. 393
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(3) "Medicaid" and "medical assistance program" mean the medical1
assistance program provided for in Title XIX of the Social Security Act.2
(4) "Prepaid coordinated care network" means a private entity that contracts3
with the department to provide Medicaid benefits and services to enrollees of the4
Medicaid coordinated care program known as "Bayou Health" in exchange for a5
monthly prepaid capitated amount per member.6
(5) "Primary care case management" means a system in which an entity7
contracts with the state to furnish case management services, which include but are8
not limited to the location, coordination, and monitoring of primary health care9
service to Medicaid beneficiaries.10
(6) "Secretary" means the secretary of the Department of Health and11
Hospitals.12
§460.32. Prepaid coordinated care networks; pharmaceutical and therapeutics13
committees14
On or before January 1, 2014, each prepaid coordinated care network shall15
form a body to be designated as a "Pharmaceutical and Therapeutics Committee"16
which shall develop a drug formulary and preferred drug list for the prepaid17
coordinated care network. Each Pharmaceutical and Therapeutics Committee18
created pursuant to the provisions of this Section shall meet no less frequently than19
semiannually in Baton Rouge, Louisiana. Such meetings shall be open to the public20
and shall allow for public comment prior to voting by the committee on any change21
in the preferred drug list or formulary.22
§460.33. Prior authorization form; requirements23
A. All managed care organizations shall accept, in addition to any currently24
accepted facsimile and electronic prior authorization forms, a standard prior25
authorization form, not to exceed two pages, excluding guidelines or instructions,26
that has been duly promulgated by the department in accordance with the27
Administrative Procedure Act. A health care provider may submit the prior28
authorization form electronically if the managed care organization allows for29
submission of the form in this manner.30 ENROLLEDHB NO. 393
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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 will be expected to be ineffective based20
on the known relevant physical or mental characteristics and medical history of the21
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
than the duration of action for the medication as described in the pharmacokinetics28
section of the package insert approved by the United States Food and Drug29 ENROLLEDHB NO. 393
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Administration when such treatment is demonstrated by the prescribing physician1
to be clinically ineffective.2
§460.35. Exemptions3
The provisions of this Part shall not apply to any entity that contracts with the4
department to provide fiscal intermediary services in processing claims of health care5
providers.6
Section 2. This Act shall become effective on January 1, 2014.7
SPEAKER OF THE HOUSE OF REPRESENTATI VES
PRESIDENT OF THE SENATE
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED: