02-04 10:59 H.B. 409
1
Medicaid Pharmacy Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Bridger Bolinder
Senate Sponsor:
2
3
LONG TITLE
4
General Description:
5
This bill amends provisions related to Medicaid pharmacy benefits.
6
Highlighted Provisions:
7
This bill:
8
▸ requires Medicaid pharmacy benefits to be provided through the fee-for-service Medicaid
9
model.
10
Money Appropriated in this Bill:
11
None
12
Other Special Clauses:
13
None
14
Utah Code Sections Affected:
15
AMENDS:
16
26B-3-105, as renumbered and amended by Laws of Utah 2023, Chapter 306
17
18
Be it enacted by the Legislature of the state of Utah:
19
Section 1. Section 26B-3-105 is amended to read:
20
26B-3-105 . Medicaid drug program -- Preferred drug list.
21
(1) A Medicaid drug program developed by the department under Subsection
22
26B-3-104(2)(f):
23
(a) shall, notwithstanding Subsection 26B-3-104(1)(b), be based on clinical and
24
cost-related factors which include medical necessity as determined by a provider in
25
accordance with administrative rules established by the Drug Utilization Review
26
Board;
27
(b) may include therapeutic categories of drugs that may be exempted from the drug
28
program;
29
(c) may include placing some drugs, except the drugs described in Subsection (2), on a
30
preferred drug list:
H.B. 409 H.B. 409 02-04 10:59
31
(i) to the extent determined appropriate by the department; and
32
(ii) in the manner described in Subsection (3) for psychotropic drugs;
33
(d) notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
34
regarding the Drug Utilization Review Board, and except as provided in Subsection
35
(3), shall immediately implement the prior authorization requirements for a
36
nonpreferred drug that is in the same therapeutic class as a drug that is:
37
(i) on the preferred drug list on the date that this act takes effect; or
38
(ii) added to the preferred drug list after this act takes effect; and
39
(e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior
40
authorization requirements established under Subsections (1)(c) and (d) which shall
41
permit a health care provider or the health care provider's agent to obtain a prior
42
authorization override of the preferred drug list through the department's pharmacy
43
prior authorization review process, and which shall:
44
(i) provide either telephone or fax approval or denial of the request within 24 hours of
45
the receipt of a request that is submitted during normal business hours of Monday
46
through Friday from 8 a.m. to 5 p.m.;
47
(ii) provide for the dispensing of a limited supply of a requested drug as determined
48
appropriate by the department in an emergency situation, if the request for an
49
override is received outside of the department's normal business hours; and
50
(iii) require the health care provider to provide the department with documentation of
51
the medical need for the preferred drug list override in accordance with criteria
52
established by the department in consultation with the Pharmacy and Therapeutics
53
Committee.
54
(2)(a) As used in this Subsection (2):
55
(i) "Immunosuppressive drug":
56
(A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
57
activity of the immune system to aid the body in preventing the rejection of
58
transplanted organs and tissue; and
59
(B) does not include drugs used for the treatment of autoimmune disease or
60
diseases that are most likely of autoimmune origin.
61
(ii) "Stabilized" means a health care provider has documented in the patient's medical
62
chart that a patient has achieved a stable or steadfast medical state within the past
63
90 days using a particular psychotropic drug.
64
(b) A preferred drug list developed under the provisions of this section may not include
- 2 - 02-04 10:59 H.B. 409
65
an immunosuppressive drug.
66
(c)(i) The state Medicaid program shall reimburse for a prescription for an
67
immunosuppressive drug as written by the health care provider for a patient who
68
has undergone an organ transplant.
69
(ii) For purposes of Subsection 58-17b-606(4), and with respect to patients who have
70
undergone an organ transplant, the prescription for a particular
71
immunosuppressive drug as written by a health care provider meets the criteria of
72
demonstrating to the department a medical necessity for dispensing the prescribed
73
immunosuppressive drug.
74
(d) Notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
75
regarding the Drug Utilization Review Board, the state Medicaid drug program may
76
not require the use of step therapy for immunosuppressive drugs without the written
77
or oral consent of the health care provider and the patient.
78
(e) The department may include a sedative hypnotic on a preferred drug list in
79
accordance with Subsection (2)(f).
80
(f) The department shall grant a prior authorization for a sedative hypnotic that is not on
81
the preferred drug list under Subsection (2)(e), if the health care provider has
82
documentation related to one of the following conditions for the Medicaid client:
83
(i) a trial and failure of at least one preferred agent in the drug class, including the
84
name of the preferred drug that was tried, the length of therapy, and the reason for
85
the discontinuation;
86
(ii) detailed evidence of a potential drug interaction between current medication and
87
the preferred drug;
88
(iii) detailed evidence of a condition or contraindication that prevents the use of the
89
preferred drug;
90
(iv) objective clinical evidence that a patient is at high risk of adverse events due to a
91
therapeutic interchange with a preferred drug;
92
(v) the patient is a new or previous Medicaid client with an existing diagnosis
93
previously stabilized with a nonpreferred drug; or
94
(vi) other valid reasons as determined by the department.
95
(g) A prior authorization granted under Subsection (2)(f) is valid for one year from the
96
date the department grants the prior authorization and shall be renewed in accordance
97
with Subsection (2)(f).
98
(3)(a) As used in this Subsection (3), "psychotropic drug" means the following classes of
- 3 - H.B. 409 02-04 10:59
99
drugs:
100
(i) atypical anti-psychotic;
101
(ii) anti-depressant;
102
(iii) anti-convulsant/mood stabilizer;
103
(iv) anti-anxiety; and
104
(v) attention deficit hyperactivity disorder stimulant.
105
(b)(i) The department shall develop a preferred drug list for psychotropic drugs.
106
(ii) Except as provided in Subsection (3)(d), a preferred drug list for psychotropic
107
drugs developed under this section shall allow a health care provider to override
108
the preferred drug list by writing "dispense as written" on the prescription for the
109
psychotropic drug.
110
(iii) A health care provider may not override Section 58-17b-606 by writing
111
"dispense as written" on a prescription.
112
(c) The department, and a Medicaid accountable care organization that is responsible for
113
providing behavioral health, shall:
114
(i) establish a system to:
115
(A) track health care provider prescribing patterns for psychotropic drugs;
116
(B) educate health care providers who are not complying with the preferred drug
117
list; and
118
(C) implement peer to peer education for health care providers whose prescribing
119
practices continue to not comply with the preferred drug list; and
120
(ii) determine whether health care provider compliance with the preferred drug list is
121
at least:
122
(A) 55% of prescriptions by July 1, 2017;
123
(B) 65% of prescriptions by July 1, 2018; and
124
(C) 75% of prescriptions by July 1, 2019.
125
(d) Beginning October 1, 2019, the department shall eliminate the dispense as written
126
override for the preferred drug list, and shall implement a prior authorization system
127
for psychotropic drugs, in accordance with Subsection (2)(f), if by July 1, 2019, the
128
department has not realized annual savings from implementing the preferred drug list
129
for psychotropic drugs of at least $750,000 General Fund savings.
130
(4) Notwithstanding Section 26B-3-202 and beginning on July 1, 2027, the Medicaid drug
131
program described in this section shall be exclusively delivered through the
132
fee-for-service Medicaid model.
- 4 - 02-04 10:59 H.B. 409
133
Section 2. Effective Date.
134
This bill takes effect on May 7, 2025.
- 5 -