2023 Connecticut General Statutes › Title 17b - Social Services › Chapter 319v - Medical Assistance › Section 17b-274. (Formerly Sec. 17-134q). - Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure.

(a) The Division of Criminal Justice shall periodically investigate pharmacies to ensure that the state is not billed for a brand name drug product when a less expensive generic substitute drug product is dispensed to a medical assistance recipient. The Commissioner of Social Services shall cooperate and provide information as requested by such division.
(b) A licensed medical practitioner may specify in writing or by a telephonic or electronic communication that there shall be no substitution for the specified brand name drug product in any prescription for a medical assistance recipient, provided (1) the practitioner specifies the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution, (2) for written and telephonic communications, the phrase “brand medically necessary” shall be in the practitioner's handwriting on the prescription form or, if the prohibition was communicated by telephonic communication, in the pharmacist's handwriting on such form, and shall not be preprinted or stamped or initialed on such form. If the practitioner specifies by telephonic communication that there shall be no substitution for the specified brand name drug product in any prescription for a medical assistance recipient, written certification in the practitioner's handwriting bearing the phrase “brand medically necessary” shall be sent to the dispensing pharmacy within ten days, and (3) for electronic communications, the prescriber shall select the code indicating that a substitution is not allowed by the pharmacy on the certified electronic prescription. A pharmacist shall dispense a generically equivalent drug product for any drug listed in accordance with 42 CFR 447.512 for a drug prescribed for a medical assistance recipient unless the prescribing practitioner has specified that there shall be no substitution for the specified brand name drug product in accordance with this subsection and such pharmacist has received approval to dispense the brand name drug product in accordance with subsection (c) of this section.
(c) The Commissioner of Social Services shall implement a procedure by which a pharmacist shall obtain approval from an independent pharmacy consultant acting on behalf of the Department of Social Services, under an administrative services only contract, whenever the pharmacist dispenses a brand name drug product to a medical assistance recipient and a chemically equivalent generic drug product substitution is available. The length of authorization for brand name drugs shall be in accordance with section 17b-491a. In cases where the brand name drug is less costly than the chemically equivalent generic drug when factoring in manufacturers' rebates, the pharmacist shall dispense the brand name drug. If such approval is not granted or denied within two hours of receipt by the commissioner of the request for approval, it shall be deemed granted. Notwithstanding any provision of this section, a pharmacist shall not dispense any initial maintenance drug prescription for which there is a chemically equivalent generic substitution that is for less than fifteen days without the department's granting of prior authorization, provided prior authorization shall not otherwise be required for atypical antipsychotic drugs if the individual is currently taking such drug at the time the pharmacist receives the prescription. The pharmacist may appeal a denial of reimbursement to the department based on the failure of such pharmacist to substitute a generic drug product in accordance with this section.
(d) A licensed medical practitioner shall disclose to the Department of Social Services or such consultant, upon request, the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution. The Commissioner of Social Services shall establish a procedure by which such a practitioner may appeal a determination that a chemically equivalent generic drug product substitution is required for a medical assistance recipient.
(P.A. 83-52, S. 1, 2, 4; P.A. 84-217, S. 1, 2; P.A. 89-111, S. 1; P.A. 93-262, S. 1, 87; P.A. 95-264, S. 46; P.A. 96-169, S. 13; June Sp. Sess. P.A. 00-2, S. 38, 53; May 9 Sp. Sess. P.A. 02-7, S. 50; P.A. 03-2, S. 52; June 30 Sp. Sess. P.A. 03-3, S. 84; P.A. 04-76, S. 16; P.A. 05-280, S. 16; P.A. 11-44, S. 128; P.A. 13-234, S. 94; P.A. 14-158, S. 1.)
History: P.A. 84-217 removed language that limited payment of fee to the period from July 1, 1983, to June 30, 1984, and increased fee from $0.25 to $0.50; P.A. 89-111 added a new Subsec. (c) containing provisions for when there is to be no substitute for the specified brand name drug product; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134q transferred to Sec. 17b-274 in 1995; P.A. 95-264 made technical changes; P.A. 96-169 amended Subsec. (b) to require the Commissioner of Social Services to cooperate and provide information as requested by the Division of Criminal Justice; June Sp. Sess. P.A. 00-2 amended Subsec. (c) to apply provisions to state-administered general assistance, general assistance and ConnPACE recipients, to require specification of the basis of medical necessity and to add provision re approval to dispense, added new Subsec. (d) requiring the Commissioner of Social Services to establish a procedure for approval of dispensing brand name drug products and added new Subsec. (e) re disclosure of the basis of medical necessity, effective July 1, 2000; May 9 Sp. Sess. P.A. 02-7 deleted former Subsec. (a) re $0.50 per prescription dispensing fee, redesignated existing Subsecs. (b) to (e) as Subsecs. (a) to (d) and amended Subsec. (c) by changing “shall establish a procedure” to “shall implement a procedure” and adding requirement that pharmacist not dispense any initial maintenance drug prescription for less than 15 days for which there is a chemically equivalent generic substitution without obtaining prior authorization from the department, such prior authorization not required for atypical antipsychotic drugs currently used by individuals at the time pharmacist receives prescription, effective August 15, 2002; P.A. 03-2 amended Subsec. (c) to add provision that chemically equivalent generic drug product substitution be available “at a lower cost” as condition precedent to requiring prior authorization for dispensing brand name drug product, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (c) to delete “at a lower cost” and add provision re dispensing of brand name drug in cases where the brand name drug is less costly than the generic drug when factoring in manufacturers' rebates, effective August 20, 2003; P.A. 04-76 amended Subsecs. (b) to (d), inclusive, by deleting references to “general assistance”; P.A. 05-280 amended Subsec. (c) by deleting provision specifying that prior authorization procedure shall not require approval other than initial prescriptions for brand name drug products and adding requirement that length of authorization for brand name drugs shall be in accordance with Sec. 17b-491a, effective July 1, 2005; P.A. 11-44 amended Subsecs. (b), (c) and (d) by deleting references to state-administered general assistance, effective July 1, 2011; P.A. 13-234 deleted references to ConnPACE, effective January 1, 2014; P.A. 14-158 replaced references to Medicaid with references to medical assistance throughout and amended Subsec. (b) to add “for written and telephonic communications” in Subdiv. (2), add Subdiv. (3) re electronic communications, replace former reference to the Code of Federal Regulations with “42 CFR 447.512” and replace reference to “brand medically necessary” with provision re prescribing practitioner has specified no substitution for brand name drug product, effective July 1, 2014.
Cited. 233 C. 557.