Utah 2025 Regular Session

Utah House Bill HB0409 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1		-	02-26 10:47 H.B. 409
	1	+	02-04 10:59 H.B. 409
2	2		1
3	3		Medicaid Pharmacy Amendments
4	4		2025 GENERAL SESSION
5	5		STATE OF UTAH
6	6		Chief Sponsor: Bridger Bolinder
7		-	Senate Sponsor: ~~Brady Brammer~~
	7	+	Senate Sponsor:
8	8		2
9	9
10	10		3
11	11		LONG TITLE
12	12		4
13	13		General Description:
14	14		5
15	15		This bill amends provisions related to Medicaid pharmacy benefits.
16	16		6
17	17		Highlighted Provisions:
18	18		7
19	19		This bill:
20	20		8
21	21		▸ requires Medicaid pharmacy benefits to be provided through the fee-for-service Medicaid
22	22		9
23	23		model.
24	24		10
25	25		Money Appropriated in this Bill:
26	26		11
27	27		None
28	28		12
29	29		Other Special Clauses:
30	30		13
31	31		None
32	32		14
33	33		Utah Code Sections Affected:
34	34		15
35	35		AMENDS:
36	36		16
37	37		26B-3-105, as renumbered and amended by Laws of Utah 2023, Chapter 306
38	38		17
39	39
40	40		18
41	41		Be it enacted by the Legislature of the state of Utah:
42	42		19
43	43		Section 1. Section 26B-3-105 is amended to read:
44	44		20
45	45		26B-3-105 . Medicaid drug program -- Preferred drug list.
46	46		21
47	47		(1) A Medicaid drug program developed by the department under Subsection
48	48		22
49	49		26B-3-104(2)(f):
50	50		23
51	51		(a) shall, notwithstanding Subsection 26B-3-104(1)(b), be based on clinical and
52	52		24
53	53		cost-related factors which include medical necessity as determined by a provider in
54	54		25
55	55		accordance with administrative rules established by the Drug Utilization Review
56	56		26
57	57		Board;
58	58		27
59	59		(b) may include therapeutic categories of drugs that may be exempted from the drug
60	60		28
61	61		program;
62	62		29
63	63		(c) may include placing some drugs, except the drugs described in Subsection (2), on a
64	64		30
65	65		preferred drug list:
66		-	H.B. 409 H.B. 409 02-26 10:47
	66	+	H.B. 409 H.B. 409 02-04 10:59
67	67		31
68	68		(i) to the extent determined appropriate by the department; and
69	69		32
70	70		(ii) in the manner described in Subsection (3) for psychotropic drugs;
71	71		33
72	72		(d) notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
73	73		34
74	74		regarding the Drug Utilization Review Board, and except as provided in Subsection
75	75		35
76	76		(3), shall immediately implement the prior authorization requirements for a
77	77		36
78	78		nonpreferred drug that is in the same therapeutic class as a drug that is:
79	79		37
80	80		(i) on the preferred drug list on the date that this act takes effect; or
81	81		38
82	82		(ii) added to the preferred drug list after this act takes effect; and
83	83		39
84	84		(e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior
85	85		40
86	86		authorization requirements established under Subsections (1)(c) and (d) which shall
87	87		41
88	88		permit a health care provider or the health care provider's agent to obtain a prior
89	89		42
90	90		authorization override of the preferred drug list through the department's pharmacy
91	91		43
92	92		prior authorization review process, and which shall:
93	93		44
94	94		(i) provide either telephone or fax approval or denial of the request within 24 hours of
95	95		45
96	96		the receipt of a request that is submitted during normal business hours of Monday
97	97		46
98	98		through Friday from 8 a.m. to 5 p.m.;
99	99		47
100	100		(ii) provide for the dispensing of a limited supply of a requested drug as determined
101	101		48
102	102		appropriate by the department in an emergency situation, if the request for an
103	103		49
104	104		override is received outside of the department's normal business hours; and
105	105		50
106	106		(iii) require the health care provider to provide the department with documentation of
107	107		51
108	108		the medical need for the preferred drug list override in accordance with criteria
109	109		52
110	110		established by the department in consultation with the Pharmacy and Therapeutics
111	111		53
112	112		Committee.
113	113		54
114	114		(2)(a) As used in this Subsection (2):
115	115		55
116	116		(i) "Immunosuppressive drug":
117	117		56
118	118		(A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
119	119		57
120	120		activity of the immune system to aid the body in preventing the rejection of
121	121		58
122	122		transplanted organs and tissue; and
123	123		59
124	124		(B) does not include drugs used for the treatment of autoimmune disease or
125	125		60
126	126		diseases that are most likely of autoimmune origin.
127	127		61
128	128		(ii) "Stabilized" means a health care provider has documented in the patient's medical
129	129		62
130	130		chart that a patient has achieved a stable or steadfast medical state within the past
131	131		63
132	132		90 days using a particular psychotropic drug.
133	133		64
134	134		(b) A preferred drug list developed under the provisions of this section may not include
135		-	- 2 - 02-26 10:47 H.B. 409
	135	+	- 2 - 02-04 10:59 H.B. 409
136	136		65
137	137		an immunosuppressive drug.
138	138		66
139	139		(c)(i) The state Medicaid program shall reimburse for a prescription for an
140	140		67
141	141		immunosuppressive drug as written by the health care provider for a patient who
142	142		68
143	143		has undergone an organ transplant.
144	144		69
145	145		(ii) For purposes of Subsection 58-17b-606(4), and with respect to patients who have
146	146		70
147	147		undergone an organ transplant, the prescription for a particular
148	148		71
149	149		immunosuppressive drug as written by a health care provider meets the criteria of
150	150		72
151	151		demonstrating to the department a medical necessity for dispensing the prescribed
152	152		73
153	153		immunosuppressive drug.
154	154		74
155	155		(d) Notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
156	156		75
157	157		regarding the Drug Utilization Review Board, the state Medicaid drug program may
158	158		76
159	159		not require the use of step therapy for immunosuppressive drugs without the written
160	160		77
161	161		or oral consent of the health care provider and the patient.
162	162		78
163	163		(e) The department may include a sedative hypnotic on a preferred drug list in
164	164		79
165	165		accordance with Subsection (2)(f).
166	166		80
167	167		(f) The department shall grant a prior authorization for a sedative hypnotic that is not on
168	168		81
169	169		the preferred drug list under Subsection (2)(e), if the health care provider has
170	170		82
171	171		documentation related to one of the following conditions for the Medicaid client:
172	172		83
173	173		(i) a trial and failure of at least one preferred agent in the drug class, including the
174	174		84
175	175		name of the preferred drug that was tried, the length of therapy, and the reason for
176	176		85
177	177		the discontinuation;
178	178		86
179	179		(ii) detailed evidence of a potential drug interaction between current medication and
180	180		87
181	181		the preferred drug;
182	182		88
183	183		(iii) detailed evidence of a condition or contraindication that prevents the use of the
184	184		89
185	185		preferred drug;
186	186		90
187	187		(iv) objective clinical evidence that a patient is at high risk of adverse events due to a
188	188		91
189	189		therapeutic interchange with a preferred drug;
190	190		92
191	191		(v) the patient is a new or previous Medicaid client with an existing diagnosis
192	192		93
193	193		previously stabilized with a nonpreferred drug; or
194	194		94
195	195		(vi) other valid reasons as determined by the department.
196	196		95
197	197		(g) A prior authorization granted under Subsection (2)(f) is valid for one year from the
198	198		96
199	199		date the department grants the prior authorization and shall be renewed in accordance
200	200		97
201	201		with Subsection (2)(f).
202	202		98
203	203		(3)(a) As used in this Subsection (3), "psychotropic drug" means the following classes of
204		-	- 3 - H.B. 409 02-26 10:47
	204	+	- 3 - H.B. 409 02-04 10:59
205	205		99
206	206		drugs:
207	207		100
208	208		(i) atypical anti-psychotic;
209	209		101
210	210		(ii) anti-depressant;
211	211		102
212	212		(iii) anti-convulsant/mood stabilizer;
213	213		103
214	214		(iv) anti-anxiety; and
215	215		104
216	216		(v) attention deficit hyperactivity disorder stimulant.
217	217		105
218	218		(b)(i) The department shall develop a preferred drug list for psychotropic drugs.
219	219		106
220	220		(ii) Except as provided in Subsection (3)(d), a preferred drug list for psychotropic
221	221		107
222	222		drugs developed under this section shall allow a health care provider to override
223	223		108
224	224		the preferred drug list by writing "dispense as written" on the prescription for the
225	225		109
226	226		psychotropic drug.
227	227		110
228	228		(iii) A health care provider may not override Section 58-17b-606 by writing
229	229		111
230	230		"dispense as written" on a prescription.
231	231		112
232	232		(c) The department, and a Medicaid accountable care organization that is responsible for
233	233		113
234	234		providing behavioral health, shall:
235	235		114
236	236		(i) establish a system to:
237	237		115
238	238		(A) track health care provider prescribing patterns for psychotropic drugs;
239	239		116
240	240		(B) educate health care providers who are not complying with the preferred drug
241	241		117
242	242		list; and
243	243		118
244	244		(C) implement peer to peer education for health care providers whose prescribing
245	245		119
246	246		practices continue to not comply with the preferred drug list; and
247	247		120
248	248		(ii) determine whether health care provider compliance with the preferred drug list is
249	249		121
250	250		at least:
251	251		122
252	252		(A) 55% of prescriptions by July 1, 2017;
253	253		123
254	254		(B) 65% of prescriptions by July 1, 2018; and
255	255		124
256	256		(C) 75% of prescriptions by July 1, 2019.
257	257		125
258	258		(d) Beginning October 1, 2019, the department shall eliminate the dispense as written
259	259		126
260	260		override for the preferred drug list, and shall implement a prior authorization system
261	261		127
262	262		for psychotropic drugs, in accordance with Subsection (2)(f), if by July 1, 2019, the
263	263		128
264	264		department has not realized annual savings from implementing the preferred drug list
265	265		129
266	266		for psychotropic drugs of at least $750,000 General Fund savings.
267	267		130
268		-	(4) Notwithstanding Section 26B-3-202 and beginning on July 1, Ĥ→ [2027]
269		-	130a
270		-	2026 ←Ĥ , the Medicaid drug
	268	+	(4) Notwithstanding Section 26B-3-202 and beginning on July 1, 2027, the Medicaid drug
271	269		131
272	270		program described in this section shall be exclusively delivered through the
273		-	- 4 - 02-26 10:47 H.B. 409
274	271		132
275	272		fee-for-service Medicaid model.
	273	+	- 4 - 02-04 10:59 H.B. 409
276	274		133
277	275		Section 2. Effective Date.
278	276		134
279	277		This bill takes effect on May 7, 2025.
280	278		- 5 -