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IC 12-15-35.5-1
Applicability
Sec. 1. This chapter applies to:
(1) the Medicaid program under this article; and
(2) the children's health insurance program under IC 12-17.6.
As added by P.L.6-2002, SEC.4. Amended by P.L.101-2005, SEC.5.
IC 12-15-35.5-2
"Cross-indicated drug" defined
Sec. 2. As used in this chapter, "cross-indicated drug" means a
drug that is used for a purpose generally held to be reasonable,
appropriate, and within the community standards of practice even
though the use is not included in the federal Food and Drug
Administration's approved labeled indications for the drug.
As added by P.L.6-2002, SEC.4.
IC 12-15-35.5-2.5
"Unrestricted access" defined
Sec. 2.5. As used in this chapter, "unrestricted access" means the
ability of a recipient to obtain a prescribed drug without being
subject to limits or preferences imposed by the office or the board for
the purpose of cost savings except as provided under section 7 of this
chapter.
As added by P.L.107-2002, SEC.23. Amended by P.L.184-2003,
SEC.10.
IC 12-15-35.5-2.6
"Waste"
Sec. 2.6. As used in this chapter, "waste" means inappropriate:
(1) overprescribing;
(2) underprescribing;
(3) overutilization;
(4) underutilization;
(5) recipient noncompliance with the prescribed regimen; or
(6) clinically unjustified utilization;
of a prescription drug.
As added by P.L.11-2010, SEC.2.
IC 12-15-35.5-3
Prohibition on prior authorization of mental health drugs;
exception
Sec. 3. (a) Except as provided in subsection (b), the office may
establish prior authorization requirements for drugs covered under a
program described in section 1 of this chapter.
(b) With the exception of prior authorization for "brand medically
necessary" of a brand name drug with a generic equivalent in
accordance with IC 16-42-22-10, the office may not require prior
authorization for the following single source or brand name
multisource drugs:
(1) A drug that is classified as an antianxiety, antidepressant, or
antipsychotic central nervous system drug in the most recent
publication of Drug Facts and Comparisons (published by the
Facts and Comparisons Division of J.B. Lippincott Company).
(2) A drug that, according to:
(A) the American Psychiatric Press Textbook of
Psychopharmacy;
(B) Current Clinical Strategies for Psychiatry;
(C) Drug Facts and Comparisons; or
(D) a publication with a focus and content similar to the
publications described in clauses (A) through (C);
is a cross-indicated drug for a central nervous system drug
classification described in subdivision (1).
(3) A drug that is:
(A) classified in a central nervous system drug category or
classification (according to Drug Facts and Comparisons)
that is created after March 12, 2002; and
(B) prescribed for the treatment of a mental illness (as
defined in the most recent publication of the American
Psychiatric Association's Diagnostic and Statistical Manual
of Mental Disorders).
(c) Except as provided under section 7 of this chapter, a recipient
enrolled in a program described in section 1 of this chapter shall have
unrestricted access to a drug described in subsection (b).
As added by P.L.6-2002, SEC.4. Amended by P.L.101-2005, SEC.6;
P.L.1-2009, SEC.104; P.L.229-2011, SEC.143.
IC 12-15-35.5-4
Prior authorization requirement parameters
Sec. 4. Prior authorization requirements developed under this
chapter must:
(1) comply with all applicable state and federal laws, including
the provisions of 405 IAC 5-3 and 42 U.S.C. 1396r-8(d)(5); and
(2) provide that the prior authorization number assigned to an
approved request be included on the prescription or drug order:
(A) issued by the prescribing practitioner; or
(B) if the prescription is transmitted orally, relayed to the
dispensing pharmacist by the prescribing practitioner.
As added by P.L.6-2002, SEC.4. Amended by P.L.107-2002, SEC.24.
IC 12-15-35.5-5
Prior authorization procedures
Sec. 5. Before requiring prior authorization for a single source
drug, the office shall seek the advice of the drug utilization review
board, established by IC 12-15-35-19, at a public meeting of the
board.
As added by P.L.6-2002, SEC.4.
IC 12-15-35.5-7
Limitations on drug refills; limitations on restrictions on certain
mental health drugs
Sec. 7. (a) Subject to subsections (b) and (c), the office may place
limits on quantities dispensed or the frequency of refills for any
covered drug as required by law or for the purpose of:
(1) preventing fraud, abuse, or waste;
(2) preventing overutilization, inappropriate utilization, or
inappropriate prescription practices that are contrary to:
(A) clinical quality and patient safety; and
(B) accepted clinical practice for the diagnosis and treatment
of mental illness and the considerations specified in
subsection (h); or
(3) implementing a disease management program.
(b) Before implementing a limit described in subsection (a), the
office shall:
(1) consider quality of care and the best interests of Medicaid
recipients;
(2) seek the advice of the drug utilization review board,
established by IC 12-15-35-19, at a public meeting of the board;
and
(3) publish a provider bulletin that complies with the
requirements of IC 12-15-13-6.
(c) Subject to subsection (d), the board may establish and the
office may implement a restriction on a drug described in section
3(b) of this chapter if:
(1) the board determines that data provided by the office
indicates that a situation described in IC 12-15-35-28(a)(8)(A)
through IC 12-15-35-28(a)(8)(K) requires an intervention to:
(A) prevent fraud, abuse, or waste;
(B) prevent overutilization, inappropriate utilization, or
inappropriate prescription practices that are contrary to:
(i) clinical quality and patient safety; and
(ii) accepted clinical practice for the diagnosis and
treatment of mental illness; or
(C) implement a disease management program; and
(2) the board approves and the office implements an educational
intervention program for providers to address the situation.
(d) A restriction established under subsection (c) for any drug
described in section 3(b) of this chapter:
(1) must comply with the procedures described in
IC 12-15-35-35;