Section 205.536 - Utilization review - Prohibition against prospective or concurrent review of prescription drug for alcohol or opioid use disorder(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 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; and2. Contains Methadone, Buprenorphine, an opioid antagonist, 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
Amended 2021 Ky. Acts ch. 201, sec. 2, effective June 29, 2021. -- Created 2018 Ky. Acts ch. 106, sec. 5, effective January 1, 2019.
Amended by 2021 Ky. Acts ch. 201,§ 2, eff. 6/29/2021.Added by 2018 Ky. Acts ch. 106,§ 5, eff. 1/1/2019.