Rep. Norm Thurston — Voting Record

Bill

Number

H.B. 409 (2025GS)

Sponsor

Rep. Bolinder, Bridger

Final action

House/ filed 3/7/2025

Outcome

Failed / filed without passage

Summary

What it does

• This bill:
• requires Medicaid pharmacy benefits to be provided through the fee-for-service Medicaid model.

Every vote on this bill

Bill text

7
26B-3-105
Medicaid Pharmacy Amendments
2025 GENERAL SESSION
STATE OF UTAH
Chief Sponsor: Bridger Bolinder
Senate Sponsor: Brady Brammer
LONG TITLE
General Description:
This bill amends provisions related to Medicaid pharmacy benefits.
Highlighted Provisions:
This bill:
requires Medicaid pharmacy benefits to be provided through the fee-for-service Medicaid 
model.
Money Appropriated in this Bill:
None
Other Special Clauses:
None
Utah Code Sections Affected:
AMENDS:
26B-3-105
, as renumbered and amended by Laws of Utah 2023, Chapter 306
Be it enacted by the Legislature of the state of Utah:
Section 1, Section 
26B-3-105
 is amended to read:
26B-3-105. Medicaid drug program -- Preferred drug list.
(1)
A Medicaid drug program developed by the department under Subsection 
26B-3-104(2)(f)
:
(a)
shall, notwithstanding Subsection 
26B-3-104(1)(b)
, be based on clinical and 
cost-related factors which include medical necessity as determined by a provider in 
accordance with administrative rules established by the Drug Utilization Review 
Board;
(b)
may include therapeutic categories of drugs that may be exempted from the drug 
program;
(c)
may include placing some drugs, except the drugs described in Subsection 
(2)
, on a 
preferred drug list:
(i)
to the extent determined appropriate by the department; and
(ii)
in the manner described in Subsection 
(3)
 for psychotropic drugs; 
(d)
notwithstanding the requirements of Sections 
26B-3-302
 through 
26B-3-309
regarding the Drug Utilization Review Board, and except as provided in Subsection 
(3)
, shall immediately implement the prior authorization requirements for a 
nonpreferred drug that is in the same therapeutic class as a drug that is:
(i)
on the preferred drug list on the date that this act takes effect; or
(ii)
added to the preferred drug list after this act takes effect; and
(e)
except as prohibited by Subsections 
58-17b-606(4)
 and 
(5)
, shall establish the prior 
authorization requirements established under Subsections 
(1)(c)
 and 
(d)
 which shall 
permit a health care provider or the health care provider's agent to obtain a prior 
authorization override of the preferred drug list through the department's pharmacy 
prior authorization review process, and which shall:
(i)
provide either telephone or fax approval or denial of the request within 24 hours of 
the receipt of a request that is submitted during normal business hours of Monday 
through Friday from 8 a.m. to 5 p.m.;
(ii)
provide for the dispensing of a limited supply of a requested drug as determined 
appropriate by the department in an emergency situation, if the request for an 
override is received outside of the department's normal business hours; and
(iii)
require the health care provider to provide the department with documentation of 
the medical need for the preferred drug list override in accordance with criteria 
established by the department in consultation with the Pharmacy and Therapeutics 
Committee.
(2)
(a)
As used in this Subsection 
(2)
:
(i)
"Immunosuppressive drug":
(A)
means a drug that is used in immunosuppressive therapy to inhibit or prevent 
activity of the immune system to aid the body in preventing the rejection of 
transplanted organs and tissue; and
(B)
does not include drugs used for the treatment of autoimmune disease or 
diseases that are most likely of autoimmune origin.
(ii)
"Stabilized" means a health care provider has documented in the patient's medical 
chart that a patient has achieved a stable or steadfast medical state within the past 
90 days using a particular psychotropic drug.
(b)
A preferred drug list developed under the provisions of this section may not include 
an immunosuppressive drug.
(c)
(i)
The state Medicaid program shall reimburse for a prescription for an 
immunosuppressive drug as written by the health care provider for a patient who 
has undergone an organ transplant.
(ii)
For purposes of Subsection 
58-17b-606(4)
, and with respect to patients who have 
undergone an organ transplant, the prescription for a particular 
immunosuppressive drug as written by a health care provider meets the criteria of 
demonstrating to the department a medical necessity for dispensing the prescribed 
immunosuppressive drug.
(d)
Notwithstanding the requirements of Sections 
26B-3-302
 through 
26B-3-309
regarding the Drug Utilization Review Board, the state Medicaid drug program may 
not require the use of step therapy for immunosuppressive drugs without the written 
or oral consent of the health care provider and the patient.
(e)
The department may include a sedative hypnotic on a preferred drug list in 
accordance with Subsection 
(2)(f)
.
(f)
The department shall grant a prior authorization for a sedative hypnotic that is not on 
the preferred drug list under Subsection 
(2)(e)
, if the health care provider has 
documentation related to one of the following conditions for the Medicaid client:
(i)
a trial and failure of at least one preferred agent in the drug class, including the 
name of the preferred drug that was tried, the length of therapy, and the reason for 
the discontinuation;
(ii)
detailed evidence of a potential drug interaction between current medication and 
the preferred drug;
(iii)
detailed evidence of a condition or contraindication that prevents the use of the 
preferred drug;
(iv)
objective clinical evidence that a patient is at high risk of adverse events due to a 
therapeutic interchange with a preferred drug;
(v)
the patient is a new or previous Medicaid client with an existing diagnosis 
previously stabilized with a nonpreferred drug; or
(vi)
other valid reasons as determined by the department.
(g)
A prior authorization granted under Subsection 
(2)(f)
 is valid for one year from the 
date the department grants the prior authorization and shall be renewed in accordance 
with Subsection 
(2)(f)
.
(3)
(a)
As used in this Subsection 
(3)
, "psychotropic drug" means the following classes of 
drugs:
(i)
atypical anti-psychotic;
(ii)
anti-depressant;
(iii)
anti-convulsant/mood stabilizer;
(iv)
anti-anxiety; and
(v)
attention deficit hyperactivity disorder stimulant.
(b)
(i)
The department shall develop a preferred drug list for psychotropic drugs.
(ii)
Except as provided in Subsection 
(3)(d)
, a preferred drug list for psychotropic 
drugs developed under this section shall allow a health care provider to override 
the preferred drug list by writing "dispense as written" on the prescription for the 
psychotropic drug.
(iii)
A health care provider may not override Section 
58-17b-606
 by writing 
"dispense as written" on a prescription.
(c)
The department, and a Medicaid accountable care organization that is responsible for 
providing behavioral health, shall:
(i)
establish a system to:
(A)
track health care provider prescribing patterns for psychotropic drugs;
(B)
educate health care providers who are not complying with the preferred drug 
list; and
(C)
implement peer to peer education for health care providers whose prescribing 
practices continue to not comply with the preferred drug list; and
(ii)
determine whether health care provider compliance with the preferred drug list is 
at least:
(A)
55% of prescriptions by July 1, 2017;
(B)
65% of prescriptions by July 1, 2018; and
(C)
75% of prescriptions by July 1, 2019.
(d)
Beginning October 1, 2019, the department shall eliminate the dispense as written 
override for the preferred drug list, and shall implement a prior authorization system 
for psychotropic drugs, in accordance with Subsection 
(2)(f)
, if by July 1, 2019, the 
department has not realized annual savings from implementing the preferred drug list 
for psychotropic drugs of at least $750,000 General Fund savings.
(4)
Notwithstanding Section 
26B-3-202
 and beginning on July 1, 2027, the Medicaid drug 
program described in this section shall be exclusively delivered through the 
fee-for-service Medicaid model.
Section 2. 
Effective Date.
This bill takes effect on 
May 7, 2025
.
2-4-25 10:59 AM