Chapter 546

2006 -- S 3180

Enacted 07/10/06

A N A C T

RELATING TO MEDICAL ASSISTANCE -- PRESCRIPTION DRUGS

Introduced By: Senator Stephen D. Alves

Date Introduced: June 20, 2006

It is enacted by the General Assembly as follows:

     SECTION 1. Title 40 of the General Laws entitled "HUMAN SERVICES" is hereby

amended by adding thereto the following chapter:

CHAPTER 21

MEDICAL ASSISTANCE -- PRESCRIPTION DRUGS

40-21-1. Prescription drug program. -- The department of human services is hereby

authorized and directed to amend its practices, procedures, regulations and the Rhode Island state

plan for medical assistance (Medicaid) pursuant to title XIX of the federal Social Security Act [42

U.S.C. § 1396 et seq.] to modify the prescription drug program:

(1) to establish a preferred drug list (PDL);

(2) to enter into supplemental rebate, discount or other agreements with pharmaceutical

companies; and

(3) to negotiate either state-specific supplemental rebates or to participate in a multi-state

pooling supplemental rebate program.

Determinations of drugs included on the PDL will be made by the State Department of

Human Services, and a listing of such drugs shall be maintained on a public website. In making

these determinations, the department shall consider the recommendations of the Medicaid

Pharmaceutical and Therapeutics Committee, whose membership shall include practicing

pharmacists and physicians, faculty members of the University of Rhode Island's College of

Pharmacy, and consumers or consumer representatives. Drugs exempt from the PDL shall

include: (1) antipsychotics; (2) anti-retrovirals; and (3) organ transplant medications. Physicians

will be informed about prior authorization procedures for medications not on the PDL, and

seventy-two (72) hour emergency supplies may be dispensed if authorizations cannot be obtained.

40-21-2. Fee-for-service program. -- The Department of Human Services is hereby

authorized and directed to amend its regulations and the Rhode Island State Plan for Medical

Assistance (Medicaid) pursuant to title XIX of the federal Social Security Act to modify the fee-

for-service program prescription drug reimbursement formula to establish a ceiling equivalent to

the combination of the manufacturer's wholesale acquisition cost and a dispensing fee of three

dollars and forty cents ($3.40) for outpatient prescriptions and two dollars and eighty-five cents

($2.85) for long-term care prescriptions.

40-21-3. Preferred drug list. – (a) If a patient's health care provider prescribes a

prescription drug that is not on the preferred drug list, the prescriber shall consult with the

program to confirm that in his or her reasonable professional judgment, the patient's clinical

condition is consistent with the criteria for approval of the nonpreferred drug. Such criteria shall

include:

(i) The preferred drug has been tried by the patient and has failed to produce the desired

health outcomes;

(ii) The patient has tried the preferred drug and has experienced unacceptable side

effects;

(iii) The patient has been stabilized on a nonpreferred drug and transition to the preferred

drug would be medically contraindicated; or

(iv) Other clinical indications identified by the committee for the patients use of the

nonpreferred drug, which shall include consideration of the medical needs of special populations,

including children, elderly, chronically ill, persons with mental health conditions, and persons

affected by HIV/AIDS.

(b) In the event that the patient does not meet the criteria in paragraph (a) of this

subdivision, the prescriber may provide additional information to the program to justify the use of

a prescription drug that is not on the preferred drug list. The program shall provide a reasonable

opportunity for a prescriber to reasonably present his or her justification of prior authorization. If,

after consultation with the program, the prescriber, in his or her reasonable professional

judgment, determines that the use of a prescription drug that is not on the preferred drug list is

warranted, the prescriber's determination shall be final.

     SECTION 2. This act shall take effect upon passage.

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LC03542

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