Sec. 46. (a) This section applies to a managed care organization that enters into an initial contract with the office to be a managed care organization after May 13, 1999.
(b) Before a managed care organization described in subsection (a) implements a formulary, the managed care organization shall submit the formulary to the office at least thirty-five (35) days before the date that the managed care organization implements the formulary for Medicaid recipients.
(c) The office shall forward the formulary to the board for the board's review and recommendation.
(d) The office shall provide at least thirty (30) days notification to the public that the board will review a managed care organization's proposed formulary at a particular board meeting. The notification shall contain the following information:
(1) A statement of the date, time, and place at which the board meeting will be convened.
(2) A general description of the subject matter of the board meeting.
(3) An explanation of how a copy of the formulary to be discussed may be obtained.
The board shall meet to review the formulary at least thirty (30) days but not more than sixty (60) days after the notification.
(e) In reviewing the formulary, the board shall do the following:
(1) Make a determination, after considering evidence and credible information provided to the board by the office and the public, that the use of the formulary will not:
(A) impede the quality of patient care in the Medicaid program; or
(B) increase costs in other parts of the Medicaid program, including hospital costs and physician costs.
(2) Make a determination that:
(A) there is access to at least two (2) alternative drugs within each therapeutic classification, if available, on the formulary;
(B) a process is in place through which a Medicaid member has access to medically necessary drugs; and
(C) the managed care organization otherwise meets the requirements of IC 27-13-38.
(f) The board shall consider:
(1) health economic data;
(2) cost data; and
(3) the use of formularies in the non-Medicaid markets;
in developing its recommendation to the office.
(g) Within thirty (30) days after the board meeting, the board shall make a recommendation to the office regarding whether the proposed formulary should be approved, disapproved, or modified.
(h) The office shall rely significantly on the clinical expertise of the board. If the office does not agree with the recommendations of the board, the office shall, at a public meeting, discuss the disagreement with the board and present any additional information to the board for the board's consideration. The board's consideration of additional information must be conducted at a public meeting.
(i) Based on the final recommendations of the board, the office shall approve, disapprove, or require modifications to the managed care organization's proposed formulary. The office shall notify the managed care organization of the office's decision within fifteen (15) days of receiving the board's final recommendation.
(j) The managed care organization must comply with the office's decision within sixty (60) days after receiving notice of the office's decision.
(k) Notwithstanding the other provisions of this section, the office may temporarily approve a managed care organization's proposed formulary pending a final recommendation from the board.
As added by P.L.231-1999, SEC.8. Amended by P.L.152-2017, SEC.29.
Structure Indiana Code
Chapter 35. Drug Utilization Review
12-15-35-1. "Appropriate and Medically Necessary" Defined
12-15-35-3. "Compendia" Defined
12-15-35-4. "Counseling" Defined
12-15-35-4.5. "Covered Outpatient Drug" Defined
12-15-35-5. "Criteria" Defined
12-15-35-6. "Drug-Disease Contraindication" Defined
12-15-35-7. "Drug-Drug Interaction" Defined
12-15-35-8. "Drug Utilization Review" or "Dur" Defined
12-15-35-9. "Intervention" Defined
12-15-35-10. "Overutilization or Underutilization" Defined
12-15-35-11. "Pharmacist" Defined
12-15-35-12. "Physician" Defined
12-15-35-13. "Prospective Dur" Defined
12-15-35-14. "Retrospective Dur" Defined
12-15-35-15. "Standards" Defined
12-15-35-17. "Therapeutic Appropriateness" Defined
12-15-35-17.5. "Therapeutic Classification" or "Therapeutic Category" Defined
12-15-35-18. "Therapeutic Duplication" Defined
12-15-35-18.5. Application of Chapter
12-15-35-18.7. Formulary Requirements
12-15-35-19. Drug Utilization Review Board; Establishment
12-15-35-20. Membership of Board
12-15-35-20.1. Conflicts of Interest
12-15-35-20.5. Therapeutics Committee Established; Members; Limitations; Terms; Votes; Meetings
12-15-35-21. Board; Appointment; Term
12-15-35-22. Qualifications of Board Members
12-15-35-23. Physician Appointments; Geographic Balance
12-15-35-24. Reappointment of Members
12-15-35-25. Chairman; Compensation; Expenses
12-15-35-27. Retrospective and Prospective Dur Program Responsibility
12-15-35-28. Duties of the Board; Preferred Drug List; Report
12-15-35-28.5. Therapeutics Committee Duties
12-15-35-29. Quorum; Majority Vote on Dur Criteria and Standards for Prescribing
12-15-35-30. Local Practices; Monitoring
12-15-35-31. Intervention; Approval; Requisites
12-15-35-32.1. Annual Report Contents
12-15-35-34. Confidential Identifying Information; Release of Cumulative Nonidentifying Information
12-15-35-35. Prior Approval Program for Outpatient Drugs; Standards
12-15-35-36. Advisory Committees
12-15-35-37. Medicaid State Plan; Inclusion of Retrospective and Prospective Dur Program
12-15-35-38. Dur Program Guidelines and Procedures
12-15-35-39. Retrospective Dur Requisites
12-15-35-40. Prospective Dur Requisites
12-15-35-41. Board Activities Under Ic 34-30-15
12-15-35-43. Confidentiality; Pharmacist Data and Information
12-15-35-44. Confidentiality; Violations; Penalty
12-15-35-45. Outpatient Drug Formulary; Requirements
12-15-35-46. Review of Proposed Formulary
12-15-35-47. Review of Changes to Formulary
12-15-35-48. Board Review of Managed Care Organization Prescription Drug Program
12-15-35-49. Information Provided by Office
12-15-35-50. Maximum Allowable Cost Schedule for Drugs; Pharmacy Participation in Medicaid Program