Page 1 of 3
Prepared by Christopher D. Adams.
Anders HB No. 393
(KEYWORD, SUMMARY, AND DIGEST as amended by Senate committee
amendments)
MEDICAID: Provides relative to prescription drug benefits of certain managed care
organizations participating in the La. Medicaid coordinated care network program
DIGEST
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 that all managed care organizations participating in the La. Medicaid
program accept, in addition to any currently accepted facsimile and electronic prior
authorization forms, a standard prior authorization form, not to exceed two pages, excluding
guidelines or instructions, that has been duly promulgated by DHH in accordance with the
APA. Proposed law provides a health care provider may submit the prior authorization form
electronically if the managed care organization allows for submission of the form in this
manner.
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
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 will be 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. Page 2 of 3
Prepared by Christopher D. Adams.
Proposed law provides that the duration of any step therapy or fail first protocol shall not be
longer than the duration of action for the medication as described in the pharmacokinetics
section of the package insert approved by the United States Food and Drug Administration
when such treatment is demonstrated by the prescribing physician to be clinically ineffective.
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
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.
Summary of Amendments Adopted by Senate Page 3 of 3
Prepared by Christopher D. Adams.
Committee Amendments Proposed by Senate Committee on Health and Welfare to the
reengrossed bill
1. Rewrites the requirements for prior authorization requirements to provide that all
managed care organizations accept, in addition to any currently accepted
facsimile and electronic prior authorization forms, a standard prior authorization
form, not to exceed two pages, excluding guidelines or instructions, that has been
duly promulgated by DHH in accordance with the APA and provides a health
care provider may submit the prior authorization form electronically if the
managed care organization allows for submission of the form in this manner.
2. Rewrites the requirements for the duration of any step therapy or fail first
protocol to provide that the duration of any step therapy or fail first protocol will
not be longer than the duration of action for the medication as described in the
pharmacokinetics section of the package insert approved by USDA when such
treatment is demonstrated by the prescribing physician to be clinically ineffective.
3. Changes from "is reasonably expected" to "will be expected" regarding the
preferred treatment required under the step therapy or fail first protocol with
regard to overrides of restricted medication treatments.