reglab/statecodes huggingface dataset:
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 34. Home Health Care Services; Office of Medicaid Policy and Planning › 12-15-34-14.7. Review of Home Health Services for Children With Complex Medical Needs

Sec. 14.7. (a) As used in this section, "office" refers to the office of the secretary of family and social services.
(b) The office shall perform a comprehensive review of existing home health services for children with complex medical needs. The office shall assess the home health services and policies for a person-centered approach that is aligned with state and federal regulations.
(c) The office shall engage stakeholders in the assessment described in subsection (b), including:
(1) consumers and family members of consumers; and
(2) home health care providers;
to solicit feedback about the issues that consumers and parents of children with complex medical needs are having with securing and maintaining home health services.
As added by P.L.113-2023, SEC.1.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-1. "Appropriate and Medically Necessary" Defined

Sec. 1. As used in this chapter, "appropriate and medically necessary" means drug prescribing, drug dispensing, and patient medication usage in conformity with the criteria and standards developed under this chapter.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-3. "Compendia" Defined

Sec. 3. As used in this chapter, "compendia" means those resources widely accepted by the medical profession in the efficacious use of drugs, including the following sources:
(1) The American Hospital Formulary Services Drug Information.
(2) The U.S. Pharmacopeia-Drug Information.
(3) The American Medical Association Drug Evaluations.
(4) The peer-reviewed medical literature.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-4. "Counseling" Defined

Sec. 4. As used in this chapter, "counseling" means the activities conducted by a pharmacist to inform Medicaid recipients about the proper use of drugs as required by the board under this chapter.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-4.5. "Covered Outpatient Drug" Defined

Sec. 4.5. As used in this chapter, "covered outpatient drug" has the meaning set forth in 42 U.S.C. 1396r-8(k)(2).
As added by P.L.107-2002, SEC.12.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-5. "Criteria" Defined

Sec. 5. As used in this chapter, "criteria" means the predetermined and explicitly accepted elements that are used to measure drug use on an ongoing basis to determine if the use is appropriate, medically necessary, and not likely to result in adverse medical outcomes.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-6. "Drug-Disease Contraindication" Defined

Sec. 6. As used in this chapter, "drug-disease contraindication" means an occurrence in which the therapeutic effect of a drug is adversely altered by the presence of another disease condition.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-7. "Drug-Drug Interaction" Defined

Sec. 7. As used in this chapter, "drug-drug interaction" means an occurrence in which at least two (2) drugs taken by a recipient leads to clinically significant toxicity that:
(1) is characteristic of one (1) or any of the drugs present; or
(2) leads to the interference with the effectiveness of one (1) or any of the drugs.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-8. "Drug Utilization Review" or "Dur" Defined

Sec. 8. As used in this chapter, "drug utilization review" or "DUR" means the program designed to measure and assess on a retrospective and a prospective basis the proper use of outpatient drugs in the Medicaid program.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-9. "Intervention" Defined

Sec. 9. As used in this chapter, "intervention" means an action taken by the board with a prescriber or pharmacist to inform about or to influence prescribing or dispensing practices or utilization of drugs.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-10. "Overutilization or Underutilization" Defined

Sec. 10. As used in this chapter, "overutilization or underutilization" means the use of a drug in such quantities where the desired therapeutic goal is not achieved.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-13. "Prospective Dur" Defined

Sec. 13. As used in this chapter, "prospective DUR" means the part of the drug utilization review program that:
(1) is to occur before the drug is dispensed;
(2) is designed to screen for potential drug therapy problems based on explicit and predetermined criteria and standards that are developed on an ongoing basis with professional input; and
(3) is to provide for the counseling of recipients about the proper use of drugs.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-14. "Retrospective Dur" Defined

Sec. 14. As used in this chapter, "retrospective DUR" means the part of the drug utilization review program that assesses or measures drug use based on an historical review of drug use data against predetermined and explicit criteria and standards that are developed on an ongoing basis with professional input.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-15. "Standards" Defined

Sec. 15. As used in this chapter, "standards" means the acceptable range of deviation from the criteria that reflects local medical practice and that is tested on the Medicaid recipient database.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-17. "Therapeutic Appropriateness" Defined

Sec. 17. As used in this chapter, "therapeutic appropriateness" means drug prescribing based on rational drug therapy that is consistent with the criteria and standards developed under this chapter.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-17.5. "Therapeutic Classification" or "Therapeutic Category" Defined

Sec. 17.5. As used in this chapter, "therapeutic classification" or "therapeutic category" means a group of pharmacologic agents primarily characterized by a significant similarity of the biochemical or physiological mechanism by which these agents result in the intended clinical outcome.
As added by P.L.107-2002, SEC.13.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-18. "Therapeutic Duplication" Defined

Sec. 18. As used in this chapter, "therapeutic duplication" means the prescribing and dispensing of:
(1) the same drug; or
(2) at least two (2) drugs from the same therapeutic class;
where overlapping periods of drug administration are involved and where such prescribing or dispensing is not medically indicated.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-18.7. Formulary Requirements

Sec. 18.7. A formulary established by a managed care organization is subject to sections 46 and 47 of this chapter.
As added by P.L.231-1999, SEC.2. Amended by P.L.152-2017, SEC.25.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-20. Membership of Board

Sec. 20. The board is composed of the following:
(1) Four (4) individuals licensed and actively engaged in the practice of medicine or osteopathic medicine in Indiana under IC 25-22.5.
(2) Four (4) individuals licensed under IC 25-26 and actively engaged in the practice of pharmacy in Indiana.
(3) One (1) individual with expertise in therapeutic pharmacology.
(4) A representative of the office who shall serve as an ex-officio nonvoting member of the board.
(5) One (1) individual who:
(A) is employed by a health maintenance organization that has a pharmacy benefit; and
(B) has expertise in formulary development and pharmacy benefit administration.
The individual appointed under this subdivision may not be employed by a health maintenance organization that is a managed care organization.
(6) One (1) individual with expertise in health economics.
As added by P.L.75-1992, SEC.19. Amended by P.L.231-1999, SEC.3; P.L.152-2017, SEC.26; P.L.114-2018, SEC.4.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-20.1. Conflicts of Interest

Sec. 20.1. (a) Each board member and each therapeutics committee member shall fully disclose any potential conflicts of interest, financial or otherwise, relating to an issue that comes before the board or committee for recommendation or other action.
(b) A board member or therapeutics committee member may not vote on a recommendation or other action if the member or the member's employer has a conflict of interest, financial or otherwise, in the outcome of the vote.
(c) A board member or therapeutics committee member who may not vote on a recommendation or other action under subsection (b) may still participate in any discussions regarding the recommendation or other action.
As added by P.L.231-1999, SEC.4. Amended by P.L.107-2002, SEC.14.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-21. Board; Appointment; Term

Sec. 21. (a) The members of the board shall be appointed by the governor and serve a term of three (3) years.
(b) The governor shall fill a vacancy on the board by appointing a new member to serve the remainder of the unexpired term.
(c) The governor may remove a member for cause.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-22. Qualifications of Board Members

Sec. 22. Board members must have expertise in one (1) or more of the following:
(1) Clinically appropriate prescribing of outpatient drugs.
(2) Clinically appropriate dispensing and monitoring of outpatient drugs.
(3) Drug utilization review, evaluation, and intervention.
(4) Medical quality assurance.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-25. Chairman; Compensation; Expenses

Sec. 25. (a) The board shall annually elect a chairman from the members of the board.
(b) The chairman may be re-elected to serve consecutive terms as chairman.
(c) A member of the board who is not a state employee is entitled to the minimum salary per diem as provided by IC 4-10-11-2.1(b). Each member of the board is entitled to reimbursement for traveling expenses and other expenses actually incurred in connection with the member's duties as provided in the state travel policies and procedures established by the Indiana department of administration and the budget agency.
(d) Each member of the board who is a state employee is entitled to reimbursement for traveling expenses actually incurred in connection with the member's duties, as provided in the state travel policies and procedures established by the Indiana department of administration and approved by the budget agency.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-26. Additional Staff

Sec. 26. (a) The secretary shall provide additional staff to the board.
(b) The secretary shall provide staff for the therapeutics committee.
As added by P.L.75-1992, SEC.19. Amended by P.L.291-2001, SEC.162; P.L.107-2002, SEC.16.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-28.5. Therapeutics Committee Duties

Sec. 28.5. The therapeutics committee established under section 20.5 of this chapter shall do the following:
(1) Advise and make recommendations to the board in the board's development and maintenance of a preferred drug list under section 28 of this chapter.
(2) Submit to the board a proposed preferred drug list that has been approved by a majority of a quorum of the therapeutics committee.
(3) Advise and make recommendations to the board in the board's review and maintenance of a preferred drug list.
As added by P.L.107-2002, SEC.18.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-28.7. Submitting Initial Preferred Drug List; Limitations on Restrictions; Advance Notice to Providers; Implementation; Prior Authorization Limitation; Rules

Sec. 28.7. (a) The board shall submit the initial approved preferred drug list to the office not later than August 1, 2002.
(b) Except as permitted under subsection (g), the office may not further restrict the status of a drug in the Medicaid program or the children's health insurance program until the board reviews a therapeutic classification and the office implements the therapeutic classification on the preferred drug list.
(c) The office shall provide advance notice to providers of the contents of the preferred drug list submitted by the board under subsection (a).
(d) Notwithstanding IC 12-15-13-6, the office shall implement any change in the preferred drug list not later than thirty (30) days after the date the board submits the amended list to the office.
(e) Except as provided by section 28(g)(3) of this chapter, the office may not implement a preferred drug list or an amendment to the preferred drug list that has not been approved by the board.
(f) The office may not require prior authorization for a drug that is excluded from the preferred drug list unless the board has made the determinations required under section 35 of this chapter.
(g) The office may adopt rules under IC 4-22-2 necessary to carry out this chapter.
As added by P.L.107-2002, SEC.19. Amended by P.L.184-2003, SEC.8.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-29. Quorum; Majority Vote on Dur Criteria and Standards for Prescribing

Sec. 29. (a) A quorum consists of six (6) voting members of the board.
(b) DUR criteria and standards for appropriate prescribing may only be implemented with the approval of a majority of the quorum of the board. The majority vote must include at least three (3) of the four (4) physician members of the board and may allow the board to accept deviations from the standards on a case-by-case basis.
As added by P.L.75-1992, SEC.19. Amended by P.L.231-1999, SEC.5.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-30. Local Practices; Monitoring

Sec. 30. The criteria and standards developed under section 28(a)(3) of this chapter for appropriate prescribing that are implemented must reflect the local practices of physicians to monitor the following:
(1) Therapeutic appropriateness.
(2) Overutilization or underutilization.
(3) Therapeutic duplication.
(4) Drug-disease contraindications.
(5) Drug-drug interactions.
(6) Incorrect drug dosage or duration of drug treatment.
(7) Clinical abuse and misuse.
As added by P.L.75-1992, SEC.19. Amended by P.L.3-2008, SEC.95.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-31. Intervention; Approval; Requisites

Sec. 31. (a) An intervention developed under section 28(a)(4) of this chapter that involves a physician must be approved by at least three (3) of the four (4) physician members of the board before implementation.
(b) An intervention that involves a pharmacist must be approved by at least three (3) of the four (4) pharmacist members of the board before implementation.
(c) Interventions include the following:
(1) Information disseminated to physicians and pharmacists to ensure that physicians and pharmacists are aware of the board's duties and powers.
(2) Written, oral, or electronic reminders of recipient-specific or drug-specific information that are designed to ensure recipient, physician, and pharmacist confidentiality, and suggested changes in the prescribing or dispensing practices designed to improve the quality of care.
(3) Use of face-to-face discussions between experts in drug therapy and the prescriber or pharmacist who has been targeted for educational intervention.
(4) Intensified reviews or monitoring of selected prescribers or pharmacists.
(5) The creation of an educational program using data provided through DUR to provide for active and ongoing educational outreach programs to improve prescribing and dispensing practices.
(6) The timely evaluation of interventions to determine if the interventions have improved the quality of care.
(7) The review of case profiles before the conducting of an intervention.
As added by P.L.75-1992, SEC.19. Amended by P.L.3-2008, SEC.96.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-32.1. Annual Report Contents

Sec. 32.1. The annual report under section 28 of this chapter shall include information on the following:
(1) A description of the nature and scope of the prospective drug review program.
(2) A description of how pharmacies performing prospective DUR without computers are expected to comply with the statutory requirement for written criteria.
(3) Detailed information on the specific criteria and standards in use and any changes in criteria.
(4) A description of the nature and scope of the retrospective DUR program.
(5) A summary of the educational interventions used and an assessment of the effect of these educational interventions on the quality of care.
(6) An estimate of the cost savings generated as a result of the DUR program including savings to the Medicaid drug program attributable to the prospective and retrospective DUR.
(7) An overview of the fiscal impact of the DUR program on other areas of the Medicaid program.
(8) A quantifiable assessment of how DUR has improved quality of care.
(9) A summary of the total number of prescriptions reviewed by drug therapeutic class.
As added by P.L.76-1994, SEC.4.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-34. Confidential Identifying Information; Release of Cumulative Nonidentifying Information

Sec. 34. (a) Information that identifies an individual collected under this chapter is confidential and may not be disclosed by the board.
(b) The board may have access to identifying information for purposes of carrying out intervention activities. The identifying information may not be released to anyone other than a member of the board.
(c) The board may release cumulative non-identifying information for purposes of legitimate research.
As added by P.L.75-1992, SEC.19.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 35. Drug Utilization Review › 12-15-35-35. Prior Approval Program for Outpatient Drugs; Standards

Sec. 35. (a) Except as provided in IC 12-15-35.5-9, before the board develops a program to place a single source drug on prior approval, restrict the drug in its use, or establish a drug monitoring process or program to measure or restrict utilization of single source drugs other than in the SURS program, the board must meet the following conditions:
(1) Make a determination, after considering evidence and credible information provided to the board by the office and the public, that placing a single source drug on prior approval or restricting the drug's use will not:
(A) impede the quality of patient care in the Medicaid program; or
(B) increase costs in other parts of the Medicaid program, including hospital costs and physician costs.
(2) Meet to review a formulary or a restriction on a single source drug after the office provides at least fifteen (15) days notification to the public that the board will review the formulary or restriction on a single source drug at a particular board meeting. The notification shall contain the following information:
(A) A statement of the date, time, and place at which the board meeting will be convened.
(B) A general description of the subject matter of the board meeting.
(C) An explanation of how a copy of the formulary to be discussed at the meeting may be obtained.
The board shall meet to review the formulary or the restriction on a single source drug at least fifteen (15) days but not more than sixty (60) days after the notification.
(3) Ensure that:
(A) there is access to at least two (2) alternative drugs within each therapeutic classification, if available, on the formulary; and
(B) a process is in place through which a Medicaid recipient has access to medically necessary drugs.
(4) Reconsider the drug's removal from its restricted status or from prior approval not later than six (6) months after the single source drug is placed on prior approval or restricted in its use.
(5) Ensure that the program provides either telephone or FAX approval or denial Monday through Friday, twenty-four (24) hours a day. The office must provide the approval or denial within twenty-four (24) hours after receipt of a prior approval request. The program must provide for the dispensing of at least a seventy-two (72) hour supply of the drug in an emergency situation or on weekends.
(6) Ensure that any prior approval program or restriction on the use of a single source drug is not applied to prevent acceptable medical use for appropriate off-label indications.
(b) The board shall advise the office on the implementation of any program to restrict the use of brand name multisource drugs.
(c) The board shall consider:
(1) health economic data;
(2) cost data; and
(3) the use of formularies in the non-Medicaid markets;
in developing its recommendations to the office.
As added by P.L.75-1992, SEC.19. Amended by P.L.76-1994, SEC.5; P.L.231-1999, SEC.6; P.L.6-2002, SEC.3; P.L.107-2002, SEC.20; P.L.1-2003, SEC.58; P.L.37-2016, SEC.1.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 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.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 36. Payments for Special Services › 12-15-36-7. Approval of More Than 100 Beds; Necessity of Agreement

Sec. 7. The office of Medicaid policy and planning may not approve more than one hundred (100) beds for special skilled services under this chapter without the agreement of the commissioner of the Indiana department of health and the administrator of the office of Medicaid policy and planning.
As added by P.L.76-1992, SEC.3. Amended by P.L.56-2023, SEC.101.
2023 Indiana Code › Title 12. Human Services › Article 15. Medicaid › Chapter 37. Medicaid Demonstration Projects › 12-15-37-1. Review of Medicaid Recipient Populations

Sec. 1. The Indiana department of health, with guidance and input from the office, shall review Medicaid recipient populations to determine which populations might benefit from transfer to an insurance product. Populations to review include participants in:
(1) the IMPACT program; and
(2) certain geographic populations, including rural populations;
to determine the fiscal and other effects of a demonstration project established for the benefit of these recipients.
As added by P.L.93-1995, SEC.4. Amended by P.L.56-2023, SEC.102.