I 
115TH CONGRESS 
2D SESSION 
H. R. 5799 
To amend title XIX of the Social Security Act to require as a condition 
of receipt of full Federal medical assistance percentage under Medicaid 
that State Medicaid plans have in place certain drug utilization review 
activities. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 15, 2018 
Mrs. BLACKBURN (for herself, Mr. BARR, and Mr. KNIGHT) introduced the 
following bill; which was referred to the Committee on Energy and Commerce 
A BILL 
To amend title XIX of the Social Security Act to require 
as a condition of receipt of full Federal medical assist-
ance percentage under Medicaid that State Medicaid 
plans have in place certain drug utilization review activi-
ties. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicaid Drug Review, 
Utilization, Good Governance Improvement Act’’ or the 
‘‘Medicaid DRUG Improvement Act’’. 
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‘‘(I) safety edits (as specified by 
the State) for subsequent fills for 
opioids and a claims review automated 
process (as designed and implemented 
by the State) that indicates when an 
individual enrolled under the State 
plan (or under a waiver of the State 
plan) is prescribed a subsequent fill of 
opioids in excess of any limitation 
that may be identified by the State; 
‘‘(II) safety edits (as specified by 
the State) on the maximum daily mor-
phine equivalent that can be pre-
scribed to an individual enrolled under 
the State plan (or under a waiver of 
the State plan) for treatment of 
chronic pain and a claims review auto-
mated process (as designed and imple-
mented by the State) that indicates 
when an individual enrolled under the 
plan (or waiver) is prescribed the mor-
phine equivalent for such treatment in 
excess of any limitation that may be 
identified by the State; and 
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‘‘(III) a claims review automated 
process (as designed and implemented 
by the State) that monitors when an 
individual enrolled under the State 
plan (or under a waiver of the State 
plan) 
is 
concurrently 
prescribed 
opioids and— 
‘‘(aa) benzodiazepines; or 
‘‘(bb) antipsychotics. 
‘‘(ii) MANAGED CARE ENTITIES.—The 
State requires each managed care entity 
(as defined in section 1932(a)(1)(B)) with 
respect to which the State has a contract 
under section 1903(m) or under section 
1905(t)(3) to have in place, subject to 
paragraph (3), with respect to individuals 
who are eligible for medical assistance 
under the State plan (or under a waiver of 
the State plan) and who are enrolled with 
the entity, the limitations described in sub-
clauses (I) and (II) of clause (i) and a 
claims review automated process described 
in subclause (III) of such clause. 
‘‘(iii) RULES
OF
CONSTRUCTION.— 
Nothing in this subparagraph may be con-
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strued as prohibiting a State or managed 
care entity from designing and imple-
menting a claims review automated process 
under this subparagraph that provides for 
prospective or retrospective reviews of 
claims. Nothing in this subparagraph shall 
be understood as prohibiting the exercise 
of clinical judgment from a provider en-
rolled as a participating provider in a 
State plan (or waiver of the State plan) or 
contracting with a managed care entity re-
garding the best items and services for an 
individual enrolled under such State plan 
(or waiver). 
‘‘(B) 
PROGRAM
TO
MONITOR 
ANTIPSYCHOTIC MEDICATIONS BY CHILDREN.— 
The State has in place a program (as designed 
and implemented by the State), including such 
a program that the State had in place before 
the date of the enactment of this subsection, to 
monitor and manage the appropriate use of 
antipsychotic medications by children enrolled 
under the State plan (or under a waiver of the 
State plan) and submits annually to the Sec-
retary such information as the Secretary may 
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require on activities carried out under such pro-
gram for individuals not more than the age of 
18 years generally and children in foster care 
specifically. 
‘‘(C) FRAUD
AND
ABUSE
IDENTIFICA-
TION.—The State has in place a process (as de-
signed and implemented by the State), includ-
ing such a process that the State had in place 
before the date of the enactment of this sub-
section, that identifies potential fraud or abuse 
of controlled substances by individuals enrolled 
under the State plan (or under a waiver of the 
State plan), health care providers prescribing 
drugs to individuals so enrolled, and pharmacies 
dispensing drugs to individuals so enrolled. 
‘‘(D) REPORTS.—The State shall include 
in the annual report submitted to the Secretary 
under section 1927(g)(3)(D) information on the 
limitations, requirement, program, and proc-
esses applied by the State under subparagraphs 
(A) through (C) in accordance with such man-
ner and time as specified by the Secretary. 
‘‘(2) ANNUAL
REPORT
BY
SECRETARY.—For 
each fiscal year beginning with fiscal year 2020, the 
Secretary shall submit to Congress a report on the 
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most recent information submitted by States under 
paragraph (1)(D). 
‘‘(3) EXCEPTIONS.— 
‘‘(A) CERTAIN INDIVIDUALS EXEMPTED.— 
The drug review and utilization requirements 
under this subsection shall not apply with re-
spect to an individual who— 
‘‘(i) is receiving— 
‘‘(I) hospice or palliative care; or 
‘‘(II) treatment for cancer; 
‘‘(ii) is a resident of a long-term care 
facility, of a facility described in section 
1905(d), or of another facility for which 
frequently abused drugs are dispensed for 
residents through a contract with a single 
pharmacy; or 
‘‘(iii) the State elects to treat as ex-
empted from such requirements. 
‘‘(B) EXCEPTION RELATING TO ENSURING 
ACCESS.—In order to ensure reasonable access 
to health care, the Secretary may waive the 
drug review and utilization requirements under 
this subsection, with respect to a State, in the 
case of natural disasters and similar situations, 
and in the case of the provision of emergency 
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services (as defined for purposes of section 
1860D–4(c)(5)(D)(ii)(II)).’’. 
(c) MANAGED CARE ENTITIES.—Section 1932 of the 
Social Security Act (42 U.S.C. 1396u–2) is amended by 
adding at the end the following new subsection: 
‘‘(i) DRUG UTILIZATION REVIEW ACTIVITIES AND 
REQUIREMENTS.—Beginning not later than October 1, 
2019, each contract under a State plan with a managed 
care entity (other than a primary care case manager) 
under section 1903(m) shall provide that the entity is in 
compliance with the applicable provisions of section 
438.3(s)(2) of title 42 of the Code of Federal Regulations, 
section 483.3(s)(4) of such title, and section 483.3(s)(5) 
of such title, as such provisions were in effect on March 
31, 2018.’’. 
Æ 
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