View Daily Data Tracking History
View Bill Text
View Statement of Purpose / Fiscal Impact
H0241....................................................by HEALTH AND WELFARE
MEDICAID - DRUG COVERAGE - Amends existing law to require negotiated
rulemaking relating to conditions for drug coverage for medicaid patients; to
establish requirements for rules adopted governing conditions for drug
coverage; and to define terms.
02/11 House intro - 1st rdg - to printing
02/12 Rpt prt - to Health/Wel
|||| LEGISLATURE OF THE STATE OF IDAHO ||||
Fifty-seventh Legislature First Regular Session - 2003
IN THE HOUSE OF REPRESENTATIVES
HOUSE BILL NO. 241
BY HEALTH AND WELFARE COMMITTEE
1 AN ACT
2 RELATING TO MEDICAID PHARMACY REIMBURSEMENT; AMENDING SECTION 56-209g, IDAHO
3 CODE, TO REQUIRE NEGOTIATED RULEMAKING RELATING TO CONDITIONS FOR DRUG
4 COVERAGE FOR MEDICAID PATIENTS, TO ESTABLISH REQUIREMENTS FOR RULES
5 ADOPTED GOVERNING CONDITIONS FOR DRUG COVERAGE AND TO DEFINE TERMS.
6 Be It Enacted by the Legislature of the State of Idaho:
7 SECTION 1. That Section 56-209g, Idaho Code, be, and the same is hereby
8 amended to read as follows:
9 56-209g. PHARMACY REIMBURSEMENT AND CONDITIONS FOR DRUG COVERAGE.
10 (1) Medicaid pharmacy reimbursement levels are a combination of the cost of
11 the drug and a dispensing fee which includes such pharmaceutical care services
12 as counseling, obtaining a patient history, documentation, and dispensing.
13 From and after January 1, 1995, through June 30, 1998 2003, it shall be the
14 policy of the state of Idaho that there be no reduction of pharmacy reimburse-
15 ment levels or conditions of drug coverage for medicaid under title XIX of the
16 social security act except as necessary to comply with federal regulations, 42
17 CFR 447.331 through 447.334, as implemented in the state of Idaho and except
18 as provided by rules promulgated by the director pursuant to the provisions of
19 this section. Effective July January 1, 1998 2003, pharmacy reimbursement lev-
20 els may and conditions for drug coverage shall be adjusted in accordance with
21 rules promulgated by the director through negotiated rulemaking with inter-
22 ested parties including, but not limited to, representatives of the pharmacy
23 profession, covered patients and the medical profession. To the extent that
24 rules promulgated by the director, that are in effect on January 1, 2003, do
25 not meet the requirements of subsections (2), (3) and (4) of this section, the
26 director shall institute negotiated rulemaking proceedings to conform such
27 rules with the requirements of this section.
28 (2) No rule promulgated by the director shall:
29 (a) Request or require, directly or indirectly, as a condition of cover-
30 age for a prescription drug for a covered patient, that a physician change
31 from a medication previously used for a particular indication for the cov-
32 ered patient to another medication based primarily on economic consider-
33 ations.
34 (b) Request or require, directly or indirectly, as a condition of a cov-
35 ered beneficiary receiving administratively authorized prompt refill or
36 renewal of a prescription, that a physician change from a medication pre-
37 viously used by the covered patient for a particular indication to another
38 medication based primarily on economic considerations.
39 (c) Employ a care management technique for covered patients (including,
40 but not limited to, implementation of a formulary, preferred drug list,
41 treatment protocol or guideline, step therapy or other use of prior autho-
42 rization) without assuring that its clinical foundation is consistent with
43 quality patient care. The assurances required for purposes of this para-
2
1 graph include evidence and documentation of:
2 (i) Clinically-based definitions for each therapeutic chemical
3 class of drugs;
4 (ii) Reliance on scientific and clinical data, supported by the pre-
5 ponderance of peer reviewed medical literature, in creating or
6 updating formularies, preferred drug lists, protocols or treatment
7 guidelines; and
8 (iii) For any drug subject to prior authorization, a specific set of
9 clinical criteria, available to physicians and covered patients,
10 specifying when that drug is authorized for coverage.
11 (iv) No rule requiring prior authorization shall restrict coverage
12 of a drug approved by the federal food and drug administration for an
13 indication unless the department has at least six (6) months of data
14 regarding the use of the drug for treating the indication in the pop-
15 ulation of covered patients.
16 (d) Request or require physicians, pharmacies and/or covered patients to
17 participate in programs that use clinical case management tools imple-
18 mented using prior authorization or approval requirements unless:
19 (i) The prior authorization system provides for real time receipt
20 of requests, by voice mail, fax, or electronic transmission, on a
21 twenty-four (24) hour basis, seven (7) days a week;
22 (ii) The prior authorization system provides in-person answers to
23 emergency requests by physician offices or pharmacies with telephone
24 answering queues that do not exceed ten (10) minutes; and
25 (iii) The prior authorization system establishes reasonable time
26 periods for answering requests for authorization or approval of drugs
27 for acute, chronic or nonacute conditions and provides coverage of an
28 initial course of therapy if such time periods are not met within the
29 established time periods.
30 (iv) A rule relating to prior authorization shall not require prior
31 authorization or approval for renewals or refills of a prescription
32 that has had prior authorization for the same prescriber for the same
33 covered patient.
34 (v) No rule shall deny the prescribing physician the right to pre-
35 scribe a drug that the physician determines, in the physician's best
36 medical judgment, is the most effective available drug to treat the
37 covered patient's health condition, notwithstanding any formulary,
38 step therapy, preferred drug list or prior authorization requirements
39 of the department.
40 (3) Rules promulgated by the director shall provide each covered patient,
41 or provider or other person on behalf of the covered patient, with an opportu-
42 nity for prompt review of a coverage denial for a drug prescribed for a medi-
43 cally accepted indication. A pharmacy benefit program shall complete its
44 review of a request for review of coverage within four (4) weeks of the date
45 of the request, whether the request is made orally or in writing. The rule
46 shall also provide for an appeal by the covered patient, or provider or other
47 person on behalf of a patient, from an adverse decision of the pharmacy bene-
48 fit program where:
49 (a) The item is not excluded from the pharmacy benefit program available
50 to covered patients, and the prescriber believes that the coverage
51 restriction imposed for the specific individual is a denial of medically
52 necessary care; or
53 (b) A pharmacy benefit program fails to issue to the covered patient
54 within seven (7) days, a written confirmation of its decision regarding
55 review of a coverage denial of an item that is not excluded from the phar-
3
1 macy program available to covered patients under the pharmacy benefit pro-
2 gram.
3 (4) As used in this section, terms used herein are defined as follows:
4 (a) "Acute condition" means a symptom, condition, or disease that is
5 expected to have a duration of two (2) weeks or less, or where prompt
6 receipt of medication is needed for infection or exposure requiring
7 antibiotics, for pain, or for life threatening symptoms.
8 (b) "Chronic condition" means a symptom, condition or disease that is
9 expected to have a duration of more than two (2) weeks.
10 (c) "Covered patient" means an individual who is enrolled to receive ben-
11 efits paid for in whole or in part by the state medicaid program,
12 children's health insurance program, or a state pharmacy benefit program.
13 (d) "Department" means the department of health and welfare of the state
14 of Idaho.
15 (e) "Emergency" means a situation in which a physician indicates that
16 delay of care exclusively to fulfill administrative requirements would be
17 medically inappropriate, and shall include any administrative delay
18 resulting from a failure to respond to a request for authorization within
19 the time periods established by rule.
20 (f) "Medically accepted indication" means use of a drug for an indication
21 that is specified in the drug's labeling, the drug compendia or peer-
22 reviewed medical literature.
23 (g) "Pharmacy benefit program" means an outpatient prescription drug ben-
24 efit established by this state under medicaid, the state children's health
25 insurance program, or a state pharmacy assistance program that is operated
26 in whole or in part by the department.
STATEMENT OF PURPOSE
RS 12761C1
The purpose of the proposed legislation is to provide a process
for future rule making by the Department of Health and Welfare
relating to the Medicaid pharmacy benefit program. The proposal
provides a negotiated rule making process that will include
pharmacists, the medical profession and representatives of
Medicaid patients.
The legislation recognizes that the Department may develop care
management techniques, including prior authorization or preferred
drug lists, and confirms that such programs be based on a
clinical foundation consistent with quality patient care. The
legislation further provides that such prior authorization
requests will be responded to in a reasonable time. The
legislation assures that rules adopted by the Department will
affirm the right of the prescribing physician to prescribe
medicines for their patients that the physician determines, in
the physician's best medical judgment, is the most effective drug
to treat the patient's health condition.
FISCAL IMPACT
There is no fiscal impact to the general fund.
Contact:
Name: Bill Roden
PhRMA
Phone: 336-7930
STATEMENT OF PURPOSE/FISCAL NOTE H 241