SSB 1169 (LSB 2149XC (1) 91)

SENATE FILE _____ 

BY  (PROPOSED COMMITTEE ON HEALTH AND HUMAN SERVICES BILL BY CHAIRPERSON KLIMESH)

A BILL FOR

An Act relating to nonopioid drugs on the medical assistance preferred drug list, and health carriers’ development of a pain management access plan.
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF IOWA:

    Section 1.  Section 249A.20A, Code 2025, is amended by adding the following new subsection:
   NEW SUBSECTION.  12.  a.  In establishing and maintaining a preferred drug list, a nonopioid drug approved by the United States food and drug administration for the treatment or management of pain shall not be disadvantaged or discouraged with respect to Medicaid coverage relative to an opioid or narcotic drug for the treatment or management of pain on the preferred drug list.
   b.  Impermissible disadvantaging or discouragement under this subsection includes all of the following:
   (1)  Designating a nonopioid drug for the treatment or management of pain as a nonpreferred drug if any opioid or narcotic drug for the treatment or management of pain is designated as a preferred drug.
   (2)  Establishing more restrictive or more extensive utilization controls, including but not limited to more restrictive or more extensive prior authorization or step therapy requirements for a nonopioid drug for the treatment or management of pain than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug for the treatment or management of pain.
   c.  This subsection shall apply to a nonopioid drug immediately upon approval of the drug by the United States food and drug administration for the treatment or management of pain, regardless of whether the drug has been reviewed by the medical assistance pharmaceutical and therapeutics committee for inclusion on the preferred drug list.
   d.  This subsection shall apply to drugs being provided under a contract between the department and a Medicaid managed care organization.
    Sec. 2.  NEW SECTION.  505.36  Health carriers —— pain management access plans.
   1.  Definitions.  As used in this section, unless the context otherwise requires:
   a.  “Covered person” means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.
   b.  “Health benefit plan” means a policy, contract, certificate, or agreement offered or issued by a health carrier to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.
   c.  “Health carrier” means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, including an insurance company offering sickness and accident plans, a health maintenance organization, a nonprofit health service corporation, a plan established pursuant to chapter 509A for public employees, or any other entity providing a plan of health insurance, health care benefits, or health care services.
   d.  “Pain management access plan” means a plan developed by a health carrier to provide adequate coverage and access to a broad spectrum of pain management alternatives under a health benefit plan.
   e.  “Pain management alternatives” means alternatives to opioid drugs including but not limited to nonopioid medicinal drugs or drug products for the treatment or management of pain, and nonpharmacologic, nonoperative pain management modalities.
   2.  Pain management access plan.  A health carrier shall develop and implement a pain management access plan that satisfies all of the following requirements:
   a.  The plan provides coverage for pain management alternatives including coverage for all of the following:
   (1)  A minimum of two alternative prescription medication treatment options that are approved by the United States food and drug administration for the treatment of pain, and that are not schedule I, II, or III controlled substances.
   (2)  A minimum of three alternative nonpharmacologic treatment modalities.
   b.  The plan does not establish utilization controls, including but not limited to prior authorization or step therapy requirements, for clinically appropriate nonopioid drugs or drug products approved by the United States food and drug administration for the treatment or management of pain, that are more restrictive or extensive than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug for the treatment or management of pain.
   3.  Filing and review.  A health carrier shall file the pain management access plan with the division for approval. In reviewing a plan, the division shall determine if the health carrier is in compliance with the requirements of this section and if any policies adopted by the health carrier may create preferential coverage of, and access to, opioid drugs.
   4.  Plan information.  A health carrier shall annually distribute educational materials about the health carrier’s pain management access plan to health care providers in the health carrier’s network, and to the health carrier’s covered persons. The health carrier shall make the pain management access plan publicly available on the health carrier’s internet site.
   5.  Rules.  The commissioner of insurance may adopt rules pursuant to chapter 17A to administer this section.
EXPLANATION
The inclusion of this explanation does not constitute agreement with
the explanation’s substance by the members of the general assembly.
   This bill relates to nonopioid drugs on the medical assistance preferred drug list, and health carriers’ development of a pain management access plan.
   Under the bill, in establishing and maintaining a preferred drug list under Code section 249A.20A, a nonopioid drug approved by the United States food and drug administration (FDA) for the treatment or management of pain shall not be disadvantaged or discouraged with respect to Medicaid coverage for an opioid or narcotic drug for the treatment or management of pain on the preferred drug list.
   Impermissible disadvantaging or discouragement of a nonopioid drug includes designating the nonopioid drug as a nonpreferred drug if any opioid or narcotic is designated as a preferred drug, and establishing more restrictive or extensive utilization controls for a nonopioid drug than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug.
   The bill applies to a nonopioid drug immediately upon its approval by the FDA for the treatment or management of pain, regardless of whether the drug has been reviewed by the medical assistance pharmaceutical and therapeutics committee for inclusion on the preferred drug list. The bill also applies to drugs being provided under a contract between the department and a Medicaid managed care organization.
   Under the bill, a health carrier shall develop and implement a pain management access plan (plan). “Pain management access plan” and “pain management alternatives” are defined in the bill.
   A plan shall provide coverage for a minimum of two alternative prescription medication treatment options that are approved by the FDA for the treatment of pain, and that are not schedule I, II, or III controlled substances; and provide coverage for a minimum of three alternative nonpharmacologic treatment modalities. A health carrier’s plan shall not establish utilization controls for clinically appropriate nonopioid drugs or drug products approved by the FDA that are more restrictive or extensive than the least restrictive or extensive utilization controls applicable to an opioid or narcotic drug.
   A health carrier shall file the plan with the insurance division for approval. In reviewing a plan, the division shall determine if the health carrier is in compliance with the bill, and if any policies adopted by the health carrier may create preferential coverage of, and access to, opioid drugs.
   A health carrier shall annually distribute educational materials to providers within the health carrier’s network, and to covered persons, about the health carrier’s plan, and shall make the plan publicly available on the health carrier’s internet site.
   The commissioner of insurance may adopt rules to administer the bill.