June 15, 2011, Introduced by Rep. Lori and referred to the Committee on Appropriations.
A bill to amend 1978 PA 368, entitled
"Public health code,"
by amending section 9709 (MCL 333.9709), as added by 2004 PA 250.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 9709. (1) Except as otherwise provided by law or in this
part, a prescriber shall obtain prior authorization for drugs that
are being provided to medicaid beneficiaries directly through the
department on a fee for service basis or pursuant to a contract for
such pharmaceutical services and that are not included on the
department's preferred drug list. If the prescriber's prior
authorization request is denied, the department or the department's
agent shall inform the requesting prescriber of his or her option
to speak to the agent's physician on duty regarding his or her
request. If immediate contact with the agent's physician on duty
cannot be arranged, the department or the department's agent shall
inform the requesting prescriber of his or her right to request a
72-hour supply of the nonauthorized drug. If contact with the
agent's physician on duty cannot be arranged within 72 hours due to
a legal holiday, the requesting prescriber may request a longer
supply of the nonauthorized drug.
(2) The department or the department's agent shall provide
authorization for prescribed drugs that are not on its preferred
drug list if any of the following are satisfied:
(a) The prescribing physician telephones the department's
agent or certifies in writing on a form as provided by the
department that the drugs are being prescribed consistent with its
licensed indications, that no other drugs included on the preferred
drug list, in the physician's professional opinion, would offer a
comparable benefit to the patient, and that the drugs are necessary
for the continued stabilization of the patient's medical condition.
(b) The prescribing physician telephones the department's
agent or certifies in writing on a form as provided by the
department that following documented failures on earlier
prescription regimens, in the physician's professional opinion, no
other drug or drugs included on the preferred drug list can provide
a comparable benefit.
(c) The prescribing physician telephones the department's
agent or certifies in writing on a form as provided by the
department that no other drugs included on the preferred drug list,
in the physician's professional opinion, would offer a comparable
benefit to the patient and that the drugs are being prescribed to a
patient for the treatment of any symptoms or side effects that are
a direct result of treatment received for any of the following:
(i) Human immunodeficiency virus infections or the
complications of the human immunodeficiency virus or acquired
immunodeficiency syndrome.
(ii) Cancer.
(iii) Organ replacement therapy.
(iv) Epilepsy or seizure disorder.
(3)
The department or the department's agent shall provide
authorization
for a prescribed drug that is not on its preferred
drug
list if each of the following is met:
(a)
The prescribing physician has achieved advanced
specialization
training and is certified as a specialist by a
specialty
board that is recognized by the American osteopathic
association
and the council on graduate medical education or their
successor
organizations and provides documentation of his or her
certification.
(b)
The prescribing physician described in subdivision (a)
telephones
the department or certifies in writing each of the
following:
(i) The prescribed drug is being prescribed consistent
with its
licensed
indications or with generally accepted medical practice as
documented
in a standard medical reference.
(ii) The prescribed drug is being used to treat a
condition
that
is normally treated within the prescribing physician's
specialty
field.
(iii) In the physician's professional opinion, no other
drug or
drugs
included on the preferred drug list can provide a comparable
benefit.
(3) (4)
Documentation of necessity or
failures under
subsection
(2) or (3) may be provided by telephone, facsimile, or
electronic transmission.
(4) (5)
A patient who is under a court
order for a particular
prescription drug before becoming a recipient of medicaid is exempt
from the prior authorization process and may continue on that
medication for the duration of the order.
(6)
Except as otherwise provided under this subsection, a
patient
who is currently under medical treatment and whose
condition
has been stabilized under a given prescription regimen
before
becoming a recipient of medicaid is exempt from the prior
authorization
process and may continue on that medication for the
current
course of treatment if without that prescription regimen
the
patient would suffer serious health consequences. Unless a
controlled
substance is currently being prescribed under a
patient's
hospice plan of care, a continuing prescription for a
controlled
substance under this subsection requires prior
authorization.
The department or the department's agent shall not
deny
a request for prior authorization of a controlled substance
under
this subsection unless the department or the department's
agent
determines that the controlled substance or the dosage of the
controlled
substance being prescribed is not consistent with its
licensed
indications or with generally accepted medical practice as
documented
in a standard medical reference.
(5) (7)
This section does not apply to
drugs being provided
under a contract between the department and a health maintenance
organization.