02-26 10:47 H.B. 409
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Medicaid Pharmacy Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Bridger Bolinder
Senate Sponsor: Brady Brammer
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LONG TITLE
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General Description:
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This bill amends provisions related to Medicaid pharmacy benefits.
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Highlighted Provisions:
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This bill:
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▸ requires Medicaid pharmacy benefits to be provided through the fee-for-service Medicaid
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model.
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Money Appropriated in this Bill:
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None
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Other Special Clauses:
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None
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Utah Code Sections Affected:
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AMENDS:
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26B-3-105, as renumbered and amended by Laws of Utah 2023, Chapter 306
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Be it enacted by the Legislature of the state of Utah:
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Section 1. Section 26B-3-105 is amended to read:
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26B-3-105 . Medicaid drug program -- Preferred drug list.
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(1) A Medicaid drug program developed by the department under Subsection
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26B-3-104(2)(f):
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(a) shall, notwithstanding Subsection 26B-3-104(1)(b), be based on clinical and
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cost-related factors which include medical necessity as determined by a provider in
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accordance with administrative rules established by the Drug Utilization Review
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Board;
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(b) may include therapeutic categories of drugs that may be exempted from the drug
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program;
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(c) may include placing some drugs, except the drugs described in Subsection (2), on a
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preferred drug list:
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(i) to the extent determined appropriate by the department; and
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(ii) in the manner described in Subsection (3) for psychotropic drugs;
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(d) notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
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regarding the Drug Utilization Review Board, and except as provided in Subsection
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(3), shall immediately implement the prior authorization requirements for a
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nonpreferred drug that is in the same therapeutic class as a drug that is:
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(i) on the preferred drug list on the date that this act takes effect; or
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(ii) added to the preferred drug list after this act takes effect; and
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(e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior
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authorization requirements established under Subsections (1)(c) and (d) which shall
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permit a health care provider or the health care provider's agent to obtain a prior
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authorization override of the preferred drug list through the department's pharmacy
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prior authorization review process, and which shall:
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(i) provide either telephone or fax approval or denial of the request within 24 hours of
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the receipt of a request that is submitted during normal business hours of Monday
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through Friday from 8 a.m. to 5 p.m.;
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(ii) provide for the dispensing of a limited supply of a requested drug as determined
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appropriate by the department in an emergency situation, if the request for an
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override is received outside of the department's normal business hours; and
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(iii) require the health care provider to provide the department with documentation of
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the medical need for the preferred drug list override in accordance with criteria
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established by the department in consultation with the Pharmacy and Therapeutics
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Committee.
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(2)(a) As used in this Subsection (2):
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(i) "Immunosuppressive drug":
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(A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
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activity of the immune system to aid the body in preventing the rejection of
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transplanted organs and tissue; and
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(B) does not include drugs used for the treatment of autoimmune disease or
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diseases that are most likely of autoimmune origin.
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(ii) "Stabilized" means a health care provider has documented in the patient's medical
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chart that a patient has achieved a stable or steadfast medical state within the past
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90 days using a particular psychotropic drug.
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(b) A preferred drug list developed under the provisions of this section may not include
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an immunosuppressive drug.
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(c)(i) The state Medicaid program shall reimburse for a prescription for an
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immunosuppressive drug as written by the health care provider for a patient who
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has undergone an organ transplant.
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(ii) For purposes of Subsection 58-17b-606(4), and with respect to patients who have
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undergone an organ transplant, the prescription for a particular
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immunosuppressive drug as written by a health care provider meets the criteria of
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demonstrating to the department a medical necessity for dispensing the prescribed
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immunosuppressive drug.
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(d) Notwithstanding the requirements of Sections 26B-3-302 through 26B-3-309
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regarding the Drug Utilization Review Board, the state Medicaid drug program may
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not require the use of step therapy for immunosuppressive drugs without the written
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or oral consent of the health care provider and the patient.
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(e) The department may include a sedative hypnotic on a preferred drug list in
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accordance with Subsection (2)(f).
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(f) The department shall grant a prior authorization for a sedative hypnotic that is not on
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the preferred drug list under Subsection (2)(e), if the health care provider has
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documentation related to one of the following conditions for the Medicaid client:
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(i) a trial and failure of at least one preferred agent in the drug class, including the
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name of the preferred drug that was tried, the length of therapy, and the reason for
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the discontinuation;
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(ii) detailed evidence of a potential drug interaction between current medication and
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the preferred drug;
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(iii) detailed evidence of a condition or contraindication that prevents the use of the
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preferred drug;
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(iv) objective clinical evidence that a patient is at high risk of adverse events due to a
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therapeutic interchange with a preferred drug;
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(v) the patient is a new or previous Medicaid client with an existing diagnosis
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previously stabilized with a nonpreferred drug; or
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(vi) other valid reasons as determined by the department.
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(g) A prior authorization granted under Subsection (2)(f) is valid for one year from the
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date the department grants the prior authorization and shall be renewed in accordance
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with Subsection (2)(f).
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(3)(a) As used in this Subsection (3), "psychotropic drug" means the following classes of
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drugs:
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(i) atypical anti-psychotic;
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(ii) anti-depressant;
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(iii) anti-convulsant/mood stabilizer;
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(iv) anti-anxiety; and
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(v) attention deficit hyperactivity disorder stimulant.
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(b)(i) The department shall develop a preferred drug list for psychotropic drugs.
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(ii) Except as provided in Subsection (3)(d), a preferred drug list for psychotropic
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drugs developed under this section shall allow a health care provider to override
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the preferred drug list by writing "dispense as written" on the prescription for the
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psychotropic drug.
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(iii) A health care provider may not override Section 58-17b-606 by writing
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"dispense as written" on a prescription.
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(c) The department, and a Medicaid accountable care organization that is responsible for
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providing behavioral health, shall:
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(i) establish a system to:
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(A) track health care provider prescribing patterns for psychotropic drugs;
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(B) educate health care providers who are not complying with the preferred drug
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list; and
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(C) implement peer to peer education for health care providers whose prescribing
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practices continue to not comply with the preferred drug list; and
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(ii) determine whether health care provider compliance with the preferred drug list is
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at least:
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(A) 55% of prescriptions by July 1, 2017;
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(B) 65% of prescriptions by July 1, 2018; and
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(C) 75% of prescriptions by July 1, 2019.
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(d) Beginning October 1, 2019, the department shall eliminate the dispense as written
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override for the preferred drug list, and shall implement a prior authorization system
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for psychotropic drugs, in accordance with Subsection (2)(f), if by July 1, 2019, the
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department has not realized annual savings from implementing the preferred drug list
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for psychotropic drugs of at least $750,000 General Fund savings.
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(4) Notwithstanding Section 26B-3-202 and beginning on July 1, Ĥ→ [2027]
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2026 ←Ĥ , the Medicaid drug
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program described in this section shall be exclusively delivered through the
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fee-for-service Medicaid model.
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Section 2. Effective Date.
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This bill takes effect on May 7, 2025.
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