reglab/housing_qa huggingface dataset:
IN Code § 12-15-35-37 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-37. Medicaid State Plan; Inclusion of Retrospective and Prospective Dur Program

Sec. 37. The board shall, in cooperation with the secretary, include in the Medicaid state plan the creation and implementation of a retrospective and prospective DUR program for Medicaid outpatient drugs to ensure that the prescriptions are appropriate, medically necessary, and not likely to result in adverse medical outcomes.As added by P.L.75-1992, SEC.19.
IN Code § 12-15-35-38 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-38. Dur Program Guidelines and Procedures

Sec. 38. The retrospective and prospective DUR program shall be operated under the guidelines and procedures established by the board under section 29 of this chapter.As added by P.L.75-1992, SEC.19.
IN Code § 12-15-35-39 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-39. Retrospective Dur Requisites

Sec. 39. Retrospective DUR must:(1) be based on the guidelines established by the board; and(2) use the mechanized drug claims processing and information retrieval system to analyze claims data to do the following:(A) Identify patterns of fraud, abuse, gross overuse, and inappropriate or medically unnecessary care.(B) Assess data on drug use against explicit predetermined standards that are based on the compendia and other sources to monitor the following:(i) Therapeutic appropriateness.(ii) Overutilization or underutilization.(iii) Therapeutic duplication.(iv) Drug-disease contraindications.(v) Drug-drug interactions.(vi) Incorrect drug dosage or duration of drug treatment.(vii) Clinical abuse and misuse.As added by P.L.75-1992, SEC.19.
IN Code § 12-15-35-40 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-40. Prospective Dur Requisites

Sec. 40. Prospective DUR must be based on the guidelines established by the board and must provide that prior to the prescription being filled or delivered a review will be conducted by the pharmacist at the point of sale to screen for potential drug therapy problems resulting from the following:(1) Therapeutic duplication.(2) Drug-drug interactions.(3) Incorrect dosage and duration of treatment.(4) Drug-allergy interactions.(5) Clinical abuse and misuse.As added by P.L.75-1992, SEC.19.
IN Code § 12-15-35-41 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-41. Board Activities Under Ic 34-30-15

Sec. 41. The activities of the board in carrying out this chapter are covered under IC 34-30-15.As added by P.L.75-1992, SEC.19. Amended by P.L.1-1998, SEC.103.
IN Code § 12-15-35-42 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-42. Meetings

Sec. 42. (a) The board may meet in an executive session for purposes of reviewing DUR data or to conduct or to discuss activity as provided for in IC 5-14-1.5-6.1.(b) The board shall also conduct regular public meetings to gather input from the public on the operation of the DUR program.(c) The board shall meet at least once each calendar quarter.As added by P.L.75-1992, SEC.19. Amended by P.L.291-2001, SEC.163; P.L.114-2018, SEC.5.
IN Code § 12-15-35-43 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-43. Confidentiality; Pharmacist Data and Information

Sec. 43. Confidential data or information obtained by pharmacists as part of prospective DUR are confidential but may be released to prescribers or others according to procedures established by the board.As added by P.L.75-1992, SEC.19.
IN Code § 12-15-35-43.5 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-43.5. Prohibiting the Release of Proprietary or Confidential Information Obtained Under Certain Circumstances

Sec. 43.5. (a) The board, the therapeutics committee, or the office may not release proprietary or confidential information obtained as part of the development, implementation, or maintenance of a preferred drug list under this chapter.(b) Information described in subsection (a) is confidential for purposes of IC 5-14-3-4(a)(1).As added by P.L.107-2002, SEC.21. Amended by P.L.184-2003, SEC.9.
IN Code § 12-15-35-44 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-44. Confidentiality; Violations; Penalty

Sec. 44. A person who does not comply with the confidentiality provisions under section 34 of this chapter commits a Class A misdemeanor.As added by P.L.75-1992, SEC.19. Amended by P.L.1-1993, SEC.133.
IN Code § 12-15-35-45 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-45. Outpatient Drug Formulary; Requirements

Sec. 45. (a) The chairman of the board, subject to the approval of the board members, may appoint an advisory committee to make recommendations to the board on the development of a Medicaid outpatient drug formulary.(b) If the office decides to establish a Medicaid outpatient drug formulary, the formulary shall be developed by the board.(c) A formulary, preferred drug list, or prescription drug benefit used by a managed care organization is subject to IC 12-15-5-5, IC 12-15-35.5, and sections 46 and 47 of this chapter.As added by P.L.76-1994, SEC.6. Amended by P.L.231-1999, SEC.7; P.L.101-2005, SEC.4; P.L.152-2017, SEC.28.
IN Code § 12-15-35-47 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-47. Review of Changes to Formulary

Sec. 47. (a) This section applies to the following changes to a formulary used by a managed care organization for Medicaid recipients:(1) Removing one (1) or more drugs from the formulary.(2) Placing new restrictions on one (1) or more drugs on the formulary.(b) Before a managed care organization makes a change described in subsection (a), the managed care organization shall submit the proposed change to the office.(c) The office shall forward the proposed change 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:(1) review the proposed change; and(2) consider evidence and credible information provided to the board;at the board's regular board meeting before making a recommendation to the office regarding whether the proposed change should be approved or disapproved.(e) Based on the final recommendation of the board, the office may approve or disapprove the proposed change. If a proposed change is not disapproved within ninety (90) days after the date the managed care organization submits the proposed change to the office, the managed care organization may implement the change to the formulary.(f) A managed care organization:(1) may add a drug to the managed care organization's formulary without the approval of the office; and(2) shall notify the office of any addition to the managed care organization's formulary within thirty (30) days after making the addition.As added by P.L.231-1999, SEC.9. Amended by P.L.152-2017, SEC.30.
IN Code § 12-15-35-48 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-48. Board Review of Managed Care Organization Prescription Drug Program

Sec. 48. (a) The board shall review the prescription drug program of a managed care organization that participates in a risk based managed care program at least one (1) time per year. The board's review of a prescription drug program must include the following:(1) An analysis of the single source drugs requiring prior authorization, including the number of drugs requiring prior authorization in comparison to other managed care organizations' prescription drug programs that participate in the state's Medicaid program.(2) A determination and analysis of the number and the type of drugs subject to a restriction.(3) A review of the rationale for:(A) the prior authorization of a drug described in subdivision (1); and(B) a restriction on a drug.(4) A review of the number of requests a managed care organization received for prior authorization, including the number of times prior authorization was approved and the number of times prior authorization was disapproved.(5) A review of:(A) patient and provider satisfaction survey reports; and(B) pharmacy-related grievance data for a twelve (12) month period.(b) A managed care organization described in subsection (a) shall provide the board with the information necessary for the board to conduct its review under subsection (a).As added by P.L.107-2002, SEC.22. Amended by P.L.205-2013, SEC.206; P.L.53-2014, SEC.106; P.L.152-2017, SEC.31; P.L.130-2018, SEC.49.
IN Code § 12-15-35-49 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-49. Information Provided by Office

Sec. 49. (a) The office shall provide the board with information necessary for the board to carry out its duties under this chapter.(b) The office shall provide the information required under subsection (a):(1) when requested by the board; and(2) in a timely manner.As added by P.L.291-2001, SEC.164.
IN Code § 12-15-35-50 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-50. Maximum Allowable Cost Schedule for Drugs; Pharmacy Participation in Medicaid Program

Sec. 50. (a) IC 12-15-13-6 does not apply to this section.(b) The office shall maintain an Internet web site and post on the web site any changes concerning the office's maximum allowable cost schedule for drugs.(c) A change in the office's maximum allowable cost schedule for drugs may not take effect less than thirty (30) days after the change is posted on the office's Internet web site.(d) The office is not required to mail a notice to providers concerning a change in the office's maximum allowable cost schedule for drugs.(e) A pharmacy may determine not to participate in the Medicaid program because of a change to the office's maximum allowable cost schedule for drugs if the pharmacy notifies the office not less than thirty (30) days after the changes take effect.As added by P.L.187-2007, SEC.8.
IN Code § 12-15-35-51 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35. Drug Utilization Review|12-15-35-51. Advisory Committee; Duties; Report

Sec. 51. (a) As used in this section, "advisory committee" refers to the mental health Medicaid quality advisory committee established by subsection (b).(b) The mental health Medicaid quality advisory committee is established. The advisory committee consists of the following members:(1) The director of the office or the director's designee, who shall serve as chairperson of the advisory committee.(2) The director of the division of mental health and addiction or the director's designee.(3) A representative of a statewide mental health advocacy organization.(4) A representative of a statewide mental health provider organization.(5) A representative from a managed care organization that participates in the state's Medicaid program.(6) A member with expertise in psychiatric research representing an academic institution.(7) A pharmacist licensed under IC 25-26.(8) The commissioner of the department of correction or the commissioner's designee.The governor shall make the appointments for a term of four (4) years under subdivisions (3) through (7) and fill any vacancy on the advisory committee.(c) The office shall staff the advisory committee. The expenses of the advisory committee shall be paid by the office.(d) Each member of the advisory committee who is not a state employee is entitled to the minimum salary per diem provided by IC 4-10-11-2.1(b). The member is also entitled to reimbursement for traveling expenses as provided under IC 4-13-1-4 and other expenses actually incurred in connection with the member's duties as provided in the state policies and procedures established by the Indiana department of administration and approved by the budget agency.(e) Each member of the advisory committee who is a state employee is entitled to reimbursement for traveling expenses as provided under IC 4-13-1-4 and other expenses actually incurred in connection with the member's duties as provided in the state policies and procedures established by the Indiana department of administration and approved by the budget agency.(f) The affirmative votes of a majority of the voting members appointed to the advisory committee are required by the advisory committee to take action on any measure.(g) The advisory committee shall advise the office and make recommendations concerning the clinical use of mental health and addiction medications, including the implementation of IC 12-15-35.5-7(c), and consider the following:(1) Peer reviewed medical literature.(2) Observational studies.(3) Health economic studies.(4) Input from physicians and patients.(5) Any other information determined by the advisory committee to be appropriate.(h) The office shall report recommendations made by the advisory committee to the drug utilization review board established by section 19 of this chapter.As added by P.L.36-2009, SEC.2. Amended by P.L.185-2013, SEC.1; P.L.205-2013, SEC.207; P.L.2-2014, SEC.65; P.L.53-2014, SEC.107; P.L.130-2018, SEC.50.
IN Code § 12-15-35.5-1 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-1. Applicability

Sec. 1. This chapter applies to:(1) the Medicaid program under this article; and(2) the children's health insurance program under IC 12-17.6.As added by P.L.6-2002, SEC.4. Amended by P.L.101-2005, SEC.5.
IN Code § 12-15-35.5-2 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-2. "Cross-Indicated Drug" Defined

Sec. 2. As used in this chapter, "cross-indicated drug" means a drug that is used for a purpose generally held to be reasonable, appropriate, and within the community standards of practice even though the use is not included in the federal Food and Drug Administration's approved labeled indications for the drug.As added by P.L.6-2002, SEC.4.
IN Code § 12-15-35.5-2.5 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-2.5. "Unrestricted Access" Defined

Sec. 2.5. As used in this chapter, "unrestricted access" means the ability of a recipient to obtain a prescribed drug without being subject to limits or preferences imposed by the office or the board for the purpose of cost savings except as provided under section 7 of this chapter.As added by P.L.107-2002, SEC.23. Amended by P.L.184-2003, SEC.10.
IN Code § 12-15-35.5-2.6 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-2.6. "Waste"

Sec. 2.6. As used in this chapter, "waste" means inappropriate:(1) overprescribing;(2) underprescribing;(3) overutilization;(4) underutilization;(5) recipient noncompliance with the prescribed regimen; or(6) clinically unjustified utilization;of a prescription drug.As added by P.L.11-2010, SEC.2.
IN Code § 12-15-35.5-3 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-3. Prohibition on Prior Authorization of Mental Health Drugs; Exception

Sec. 3. (a) Except as provided in subsection (b), the office may establish prior authorization requirements for drugs covered under a program described in section 1 of this chapter.(b) With the exception of prior authorization for "brand medically necessary" of a brand name drug with a generic equivalent in accordance with IC 16-42-22-10, the office may not require prior authorization for the following single source or brand name multisource drugs:(1) A drug that is classified as an antianxiety, antidepressant, or antipsychotic central nervous system drug in the most recent publication of Drug Facts and Comparisons (published by the Facts and Comparisons Division of J.B. Lippincott Company).(2) A drug that, according to:(A) the American Psychiatric Press Textbook of Psychopharmacy;(B) Current Clinical Strategies for Psychiatry;(C) Drug Facts and Comparisons; or(D) a publication with a focus and content similar to the publications described in clauses (A) through (C);is a cross-indicated drug for a central nervous system drug classification described in subdivision (1).(3) A drug that is:(A) classified in a central nervous system drug category or classification (according to Drug Facts and Comparisons) that is created after March 12, 2002; and(B) prescribed for the treatment of a mental illness (as defined in the most recent publication of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders).(c) The office may require prior authorization for an addictive medication used as medication assisted treatment for substance abuse.(d) Except as provided under section 7 of this chapter, a recipient enrolled in a program described in section 1 of this chapter shall have unrestricted access to a drug described in subsection (b).As added by P.L.6-2002, SEC.4. Amended by P.L.101-2005, SEC.6; P.L.1-2009, SEC.104; P.L.229-2011, SEC.143; P.L.154-2015, SEC.3.
IN Code § 12-15-35.5-4 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-4. Prior Authorization Requirement Parameters

Sec. 4. Prior authorization requirements developed under this chapter must:(1) comply with all applicable state and federal laws, including the provisions of 405 IAC 5-3 and 42 U.S.C. 1396r-8(d)(5); and(2) provide that the prior authorization number assigned to an approved request be included on the prescription or drug order:(A) issued by the prescribing practitioner; or(B) if the prescription is transmitted orally, relayed to the dispensing pharmacist by the prescribing practitioner.As added by P.L.6-2002, SEC.4. Amended by P.L.107-2002, SEC.24.
IN Code § 12-15-35.5-5 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-5. Prior Authorization Procedures

Sec. 5. Before requiring prior authorization for a single source drug, the office shall seek the advice of the drug utilization review board, established by IC 12-15-35-19, at a public meeting of the board.As added by P.L.6-2002, SEC.4.
IN Code § 12-15-35.5-6 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-6. Publication of Prior Authorization Decision

Sec. 6. (a) The office shall publish the decision to require prior authorization for a single source drug in a provider bulletin.(b) IC 12-15-13-6 applies to a provider bulletin described in subsection (a).As added by P.L.6-2002, SEC.4.
IN Code § 12-15-35.5-7.5 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-7.5. Reimbursement for Methadone When Prescribed for Pain; Requirements

Sec. 7.5. (a) The office may reimburse under Medicaid for methadone if the drug was prescribed for the treatment of pain or pain management only as follows:(1) If the daily dosage is not more than sixty (60) milligrams.(2) If the daily dosage is more than sixty (60) milligrams, only if:(A) prior authorization is obtained; and(B) a determination of medical necessity has been shown by the provider.(b) A managed care organization may reimburse under Medicaid for methadone if the drug is prescribed for the treatment of pain or pain management only as follows:(1) If the daily dosage is not more than sixty (60) milligrams.(2) If the daily dosage is more than sixty (60) milligrams, only if:(A) prior authorization is obtained; and(B) a determination of medical necessity has been shown.As added by P.L.209-2015, SEC.12.
IN Code § 12-15-35.5-8 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-8. Restriction of Mental Health Drugs for Individuals Less Than 18 Years of Age

Sec. 8. In addition to the limits described in section 7 of this chapter, the office may restrict a mental health drug described in section 3 of this chapter that is prescribed for an individual who is less than eighteen (18) years of age if federal financial participation is not available for reimbursement for the prescription under IC 12-15-5-2.As added by P.L.11-2010, SEC.3.
IN Code § 12-15-35.5-9 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 35.5. Prescription Drugs|12-15-35.5-9. Reimbursement for Drugs Indicated Only for Addiction Treatment

Sec. 9. The office may not reimburse under Medicaid for Subutex, Suboxone, or a similar trade name or generic of the drug if the drug is only indicated for addiction treatment and was prescribed for the treatment of pain or pain management.As added by P.L.37-2016, SEC.2. Amended by P.L.10-2019, SEC.60.
IN Code § 12-15-36-1 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-1. Application of Chapter

Sec. 1. This chapter applies to a health facility licensed under IC 16-28 that has been approved by the office to have more than eight (8) beds but less than forty (40) beds approved for special skilled services.As added by P.L.76-1992, SEC.3. Amended by P.L.2-1993, SEC.103.
IN Code § 12-15-36-2 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-2. "Chronically Medically Dependent" Defined

Sec. 2. As used in this chapter, "chronically medically dependent" means a medical condition of a person who is infected by the human immunodeficiency virus (HIV) and has been certified by a physician as, because of the HIV infection, requiring a skilled or intermediate level of care.As added by P.L.76-1992, SEC.3.
IN Code § 12-15-36-3 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-3. "Special Skilled Services" Defined

Sec. 3. As used in this chapter, "special skilled services" refers to medical and health services that are provided to a patient who is:(1) chronically medically dependent; and(2) in need of a level of care that is less intensive than the care provided in a hospital licensed under IC 16-21.As added by P.L.76-1992, SEC.3. Amended by P.L.2-1993, SEC.104.
IN Code § 12-15-36-4 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-4. Payment Rate; Establishment Under Federal Law

Sec. 4. The office shall, under 42 U.S.C. 1396 et seq., establish a payment rate to a health facility for special skilled services.As added by P.L.76-1992, SEC.3.
IN Code § 12-15-36-5 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-5. Payment Standards; Costs Included

Sec. 5. Payment for special skilled services provided in a health facility must meet the following conditions:(1) Be determined in accordance with a prospective payment rate that is reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities to provide care and services in conformity with applicable state and federal laws, rules, regulations, and quality and safety standards.(2) Include the increased costs for respiratory therapy, intensive case management, social services, physician and nursing care, linens, and dietary supplements.As added by P.L.76-1992, SEC.3.
IN Code § 12-15-36-6 (2021)
2021 Indiana Code|Title 12. Human Services|Article 15. Medicaid|Chapter 36. Payments for Special Services|12-15-36-6. Implementation of Chapter

Sec. 6. The office shall adopt rules under IC 4-22-2 to implement this chapter.As added by P.L.76-1992, SEC.3.