Coverage requirement of medical services and prescription medications for the treatment of dementia

A bill for an act

relating to health insurance; requiring coverage of medical services and prescription

medications for the treatment of dementia; modifying step therapy requirements

for medical assistance; amending Minnesota Statutes 2024, section 256B.0625,

subdivision 13f; proposing coding for new law in Minnesota Statutes, chapter 62Q.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

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[62Q.546] COVERAGE FOR DEMENTIA.

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(a) A health plan company must provide coverage for every (1) type of medical service,

and (2) prescription medication approved by the United States Food and Drug Administration

that is used to treat or slow the progression of dementia. A health plan company must provide

coverage for diagnostic testing to determine the appropriateness or effectiveness of a medical

service or prescription medication to treat or slow the progression of dementia.

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(b) A health plan company is prohibited from using step therapy protocol, as defined in

section 62Q.184, subdivision 1, when providing the coverage required under paragraph (a).

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EFFECTIVE DATE.

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This section is effective January 1, 2027, and applies to health

plans offered, issued, or renewed on or after that date.

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Sec. 2.

Minnesota Statutes 2024, section 256B.0625, subdivision 13f, is amended to read:

Subd. 13f.

Prior authorization.

(a) The Formulary Committee shall review and

recommend drugs which require prior authorization. The Formulary Committee shall

establish general criteria to be used for the prior authorization of brand-name drugs for

which generically equivalent drugs are available, but the committee is not required to review

each brand-name drug for which a generically equivalent drug is available.

(b) Prior authorization may be required by the commissioner before certain formulary

drugs are eligible for payment. The Formulary Committee may recommend drugs for prior

authorization directly to the commissioner. The commissioner may also request that the

Formulary Committee review a drug for prior authorization. Before the commissioner may

require prior authorization for a drug:

(1) the commissioner must provide information to the Formulary Committee on the

impact that placing the drug on prior authorization may have on the quality of patient care

and on program costs, information regarding whether the drug is subject to clinical abuse

or misuse, and relevant data from the state Medicaid program if such data is available;

(2) the Formulary Committee must review the drug, taking into account medical and

clinical data and the information provided by the commissioner; and

(3) the Formulary Committee must hold a public forum and receive public comment for

an additional 15 days.

The commissioner must provide a 15-day notice period before implementing the prior

authorization.

(c) Except as provided in subdivision 13j, prior authorization shall not be required or

utilized for any atypical antipsychotic drug prescribed for the treatment of mental illness

if:

(1) there is no generically equivalent drug available; and

(2) the drug was initially prescribed for the recipient prior to July 1, 2003; or

(3) the drug is part of the recipient's current course of treatment.

This paragraph applies to any multistate preferred drug list or supplemental drug rebate

program established or administered by the commissioner. Prior authorization shall

automatically be granted for 60 days for brand name drugs prescribed for treatment of mental

illness within 60 days of when a generically equivalent drug becomes available, provided

that the brand name drug was part of the recipient's course of treatment at the time the

generically equivalent drug became available.

(d) Prior authorization must not be required for liquid methadone if only one version of

liquid methadone is available. If more than one version of liquid methadone is available,

the commissioner shall ensure that at least one version of liquid methadone is available

without prior authorization.

(e) Prior authorization may be required for an oral liquid form of a drug, except as

described in paragraph (d). A prior authorization request under this paragraph must be

automatically approved within 24 hours if the drug is being prescribed for a Food and Drug

Administration-approved condition for a patient who utilizes an enteral tube for feedings

or medication administration, even if the patient has current or prior claims for pills for that

condition. If more than one version of the oral liquid form of a drug is available, the

commissioner may select the version that is able to be approved for a Food and Drug

Administration-approved condition for a patient who utilizes an enteral tube for feedings

or medication administration. This paragraph applies to any multistate preferred drug list

or supplemental drug rebate program established or administered by the commissioner. The

commissioner shall design and implement a streamlined prior authorization form for patients

who utilize an enteral tube for feedings or medication administration and are prescribed an

oral liquid form of a drug. The commissioner may require prior authorization for brand

name drugs whenever a generically equivalent product is available, even if the prescriber

specifically indicates "dispense as written-brand necessary" on the prescription as required

by section
151.21, subdivision 2
.

(f) Notwithstanding this subdivision, the commissioner may automatically require prior

authorization, for a period not to exceed 180 days, for any drug that is approved by the

United States Food and Drug Administration on or after July 1, 2005. The 180-day period

begins no later than the first day that a drug is available for shipment to pharmacies within

the state. The Formulary Committee shall recommend to the commissioner general criteria

to be used for the prior authorization of the drugs, but the committee is not required to

review each individual drug. In order to continue prior authorizations for a drug after the

180-day period has expired, the commissioner must follow the provisions of this subdivision.

(g) Prior authorization under this subdivision shall comply with section
62Q.184
.

(h) Any step therapy protocol requirements established by the commissioner must comply

with
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section
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sections
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62Q.1841
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and
62Q.546
. The commissioner must apply the step therapy

requirements of sections 62Q.1841 and 62Q.546 to service delivery under fee-for-service
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.

(i) Notwithstanding any law to the contrary, prior authorization or step therapy shall not

be required or utilized for any class of drugs that is approved by the United States Food and

Drug Administration for the treatment or prevention of HIV and AIDS.

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EFFECTIVE DATE.

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This section is effective January 1, 2027.

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