§ 26B-3-105 — Medicaid drug program -- Preferred drug list.

Utah § 26B-3-105

• Jurisdiction: Utah
• Title 26B: Utah Health and Human Services Code
• Ch. 26B-3: Health Care - Administration and Assistance
• Part 26B-3-1: Health Care Assistance

Text

(1) As used in this section:
(1)(a) "Immunosuppressive drug" means a drug that:
(1)(a)(i) 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
(1)(a)(ii) does not include drugs used for the treatment of autoimmune disease or diseases that are most likely of autoimmune origin.
(1)(b) "Psychotropic drug" means the following classes of drugs:
(1)(b)(i) anti-depressant;
(1)(b)(ii) anti-convulsant/mood stabilizer;
(1)(b)(iii) anti-anxiety; and
(1)(b)(iv) attention deficit hyperactivity disorder stimulant.
(1)(c) "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.
(2) A Medicaid drug program developed by the department under Subsection 26B-3-104(2)(f):
(2)(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;
(2)(b) may include therapeutic categories of drugs that may be exempted from the drug program;
(2)(c) notwithstanding Section 58-17b-606, may include placing some drugs on a preferred drug list:
(2)(c)(i) to the extent determined appropriate by the department; and
(2)(c)(ii) in the manner described in Subsection (4) for atypical anti-psychotic drugs;
(2)(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 (4), shall immediately implement the prior authorization requirements for a nonpreferred drug that is in the same therapeutic class as a drug that is:
(2)(d)(i) on the preferred drug list on the date that this act takes effect; or
(2)(d)(ii) added to the preferred drug list after this act takes effect; and
(2)(e) except as prohibited by Subsections 58-17b-606(4) and (5), shall establish the prior authorization requirements 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:
(2)(e)(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.;
(2)(e)(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
(2)(e)(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.
(3) (3)(a) A preferred drug list developed under the provisions of this section may not include an immunosuppressive drug.
(3)(a)(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.
(3)(a)(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.
(3)(a)(iii) 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.
(4) (4)(a) (4)(a)(i) The department shall include atypical anti-psychotic drugs on the preferred drug list.
(4)(a)(ii) The department shall allow a health care provider to override the preferred drug list for an atypical anti-psychotic drug by writing "dispense as written" on the prescription for the atypical anti-psychotic drug.
(4)(a)(iii) A health care provider may not override Section 58-17b-606 by writing "dispense as written" on a prescription.
(4)(b) The department, and a Medicaid accountable care organization that is responsible for providing behavioral health, shallestablish a system to:
(4)(b)(i) track health care provider prescribing patterns for atypical anti-psychotic drugs;
(4)(b)(ii) educate health care providers who are not complying with the preferred drug list; and
(4)(b)(iii) implement peer to peer education for health care providers whose prescribing practices continue to not comply with the preferred drug list.
(5) For enrollees that begin a psychotropic drug treatment on or after July 1, 2025, the department shall pay for a psychotropic drug that is not on the preferred drug list if the department, based on patient claims history or health care provider attestation, has evidence of:
(5)(a) an enrollee's trial and failure of a psychotropic drug on the preferred drug list that is equivalent or similar to the drug that is not on the preferred drug list in the last 365 days; or
(5)(b) the enrollee being stabilized on the psychotropic drug that is not on the preferred drug list at the time of enrollment.

Legislative History

Amended by Chapter 135, 2025 General Session