Kentucky Statutes 205.536 – Utilization review — Prohibition against prospective or concurrent review of prescription drug for alcohol or opioid use disorder
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(1) A Medicaid managed care organization shall have a utilization review plan, as defined in KRS § 304.17A-600, that meets the requirements established in 42 C.F.R. § pts. 431, 438, and 456. If the Medicaid managed care organization utilizes a private review agent, as defined in KRS § 304.17A-600, the agent shall comply with all applicable requirements of KRS § 304.17A-600 to KRS § 304.17A-633.
(2) In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the Department of Insurance pursuant to KRS § 304.38-240, for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan required by subsection (1) of this section.
(3) To the extent consistent with the federal regulations referenced in subsection (1) of this section, the Department for Medicaid Services or any managed care organization contracted to provide Medicaid benefits pursuant to KRS Chapter 205 shall not require or conduct a prospective or concurrent review, as defined in KRS
304.17A-600, for a prescription drug: (a) That:
1. Is used in the treatment of alcohol or opioid use disorder; and
2. Contains Methadone, Buprenorphine, or Naltrexone; or
(b) That was approved before January 1, 2022, by the United States Food and
Drug Administration for the mitigation of opioid withdrawal symptoms.
Effective: June 29, 2021
History: Amended 2021 Ky. Acts ch. 201, sec. 2, effective June 29, 2021. — Created
2018 Ky. Acts ch. 106, sec. 5, effective January 1, 2019.
(2) In conducting utilization reviews for Medicaid benefits, each Medicaid managed care organization shall use the medical necessity criteria selected by the Department of Insurance pursuant to KRS § 304.38-240, for making determinations of medical necessity and clinical appropriateness pursuant to the utilization review plan required by subsection (1) of this section.
Terms Used In Kentucky Statutes 205.536
- Federal: refers to the United States. See Kentucky Statutes 446.010
- Treatment: when used in a criminal justice context, means targeted interventions
that focus on criminal risk factors in order to reduce the likelihood of criminal behavior. See Kentucky Statutes 446.010
(3) To the extent consistent with the federal regulations referenced in subsection (1) of this section, the Department for Medicaid Services or any managed care organization contracted to provide Medicaid benefits pursuant to KRS Chapter 205 shall not require or conduct a prospective or concurrent review, as defined in KRS
304.17A-600, for a prescription drug: (a) That:
1. Is used in the treatment of alcohol or opioid use disorder; and
2. Contains Methadone, Buprenorphine, or Naltrexone; or
(b) That was approved before January 1, 2022, by the United States Food and
Drug Administration for the mitigation of opioid withdrawal symptoms.
Effective: June 29, 2021
History: Amended 2021 Ky. Acts ch. 201, sec. 2, effective June 29, 2021. — Created
2018 Ky. Acts ch. 106, sec. 5, effective January 1, 2019.