§346-59.9 Psychotropic medication. (a) This section shall apply only to the medicaid managed care and fee-for-service programs administered by the department when the department or the department's contracted health plan is the primary insurer. When the department is the secondary insurer, the department and its contracted health plans shall be responsible only for the secondary insurer’s share of any psychotropic medication covered by the primary insurer.
(b) The department and its contracted health plans shall not impose any restriction or limitation on the coverage for, or a recipient's access to, antipsychotic medication.
(c) The department and its contracted health plans shall not impose any restriction or limitation on the coverage for, or a recipient's access to, antidepressant medication other than:
(1) Requiring that an individual must have two failed attempts on a generic antidepressant medication to receive coverage for a new brand-name antidepressant prescription; and
(2) Requiring that if an individual does not have two failed attempts on a generic antidepressant medication, that individual shall receive coverage for a brand-name antidepressant medication with prior authorization by the contracted health plan; provided that while a prior authorization request for a brand-name antidepressant medication submitted by the prescriber is pending, a supply of the prescribed medication sufficient to last until the request is resolved shall be covered if requested by the prescriber.
For purposes of this subsection, a "failed attempt" means that the prescribed generic antidepressant medication up to the maximum FDA-approved dosage is not effective in treating the individual, or the individual's compliance is compromised due to the side effects caused by the medication.
(d) The department and its contracted health plans shall not impose any restriction or limitation on the coverage for, or a recipient's access to, anti-anxiety medication other than:
(1) Requiring that an individual must have two failed attempts on a generic anti-anxiety medication to receive coverage for a new brand-name anti-anxiety prescription; and
(2) Requiring that if an individual does not have two failed attempts on a generic anti-anxiety medication, that individual shall receive coverage for a brand-name anti-anxiety medication with prior authorization by the contracted health plan; provided that while a prior authorization request for a brand-name anti-anxiety medication submitted by the prescriber is pending, a supply of the prescribed medication sufficient to last until the request is resolved shall be covered if requested by the prescriber.
For purposes of this subsection, a "failed attempt" means that the prescribed generic anti-anxiety medication up to the maximum FDA-approved dosage is not effective in treating the individual, or the individual's compliance is compromised due to the side effects caused by the medication.
(e) The department and its contracted health plans shall not require any individual stable on a brand-name antidepressant medication on or before July 1, 2010, to transfer to a different antidepressant medication, generic or brand-name, unless the individual's condition becomes unstable and requires the medication to be replaced.
(f) The department and its contracted health plans shall not require any individual stable on a brand-name anti-anxiety medication on or before July 1, 2010, to transfer to a different anti-anxiety medication, generic or brand-name, unless the individual's condition becomes unstable and requires the medication to be replaced.
(g) The department and its medicaid managed care contracted health plans shall have the authority to investigate fraud, abuse, or misconduct.
(h) The department shall report to the legislature no later than twenty days before the convening of each regular session on:
(1) The number of brand-name and generic prescriptions written to which this section applies; and
(2) The amount expended on brand-name prescriptions and the amount expended on generic prescriptions written each fiscal year to which this section applies.
(i) All psychotropic medications covered by this section shall be prescribed by a psychiatrist, a physician, or an advanced practice registered nurse with prescriptive authority under chapter 457 and duly licensed in the State.
(j) As used in this section:
"Anti-anxiety medication" means those medications included in the United States Pharmacopeia's anxiolytic therapeutic category.
"Antidepressant medication" means those medications included in the United States Pharmacopeia's antidepressant therapeutic category.
"Antipsychotic medication" means those medications included in the United States Pharmacopeia's antipsychotic therapeutic category.
"Psychotropic medication" means only antipsychotic, antidepressant, or anti-anxiety medications approved by the United States Food and Drug Administration for the treatment of mental or emotional disorders. [L 2005, c 239, pt of §2, §5; am L 2006, c 311, pt of §2, §3; am L 2007, c 39, §§1, 2; am L 2010, c 205, §§2, 9; am L 2012, c 120, §2; am L 2015, c 20, §§6, 7]