HF 1269

as introduced - 94th Legislature (2025 - 2026) Posted on 03/05/2025 11:29am

A bill for an act
relating to health insurance; requiring coverage of medical services and prescription
medications for the treatment of dementia; modifying step therapy requirements
for medical assistance; amending Minnesota Statutes 2024, section 256B.0625,
subdivision 13f; proposing coding for new law in Minnesota Statutes, chapter 62Q.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

new text begin [62Q.546] COVERAGE FOR DEMENTIA.
new text end

new text begin (a) A health plan company must provide coverage for every (1) type of medical service,
and (2) prescription medication approved by the United States Food and Drug Administration
that is used to treat or slow the progression of dementia. A health plan company must provide
coverage for diagnostic testing to determine the appropriateness or effectiveness of a medical
service or prescription medication to treat or slow the progression of dementia.
new text end

new text begin (b) A health plan company is prohibited from using step therapy protocol, as defined in
section 62Q.184, subdivision 1, when providing the coverage required under paragraph (a).
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2026, and applies to health
plans offered, issued, or renewed on or after that date.
new text end

Sec. 2.

Minnesota Statutes 2024, section 256B.0625, subdivision 13f, is amended to read:

Subd. 13f.

Prior authorization.

(a) The Formulary Committee shall review and
recommend drugs which require prior authorization. The Formulary Committee shall
establish general criteria to be used for the prior authorization of brand-name drugs for
which generically equivalent drugs are available, but the committee is not required to review
each brand-name drug for which a generically equivalent drug is available.

(b) Prior authorization may be required by the commissioner before certain formulary
drugs are eligible for payment. The Formulary Committee may recommend drugs for prior
authorization directly to the commissioner. The commissioner may also request that the
Formulary Committee review a drug for prior authorization. Before the commissioner may
require prior authorization for a drug:

(1) the commissioner must provide information to the Formulary Committee on the
impact that placing the drug on prior authorization may have on the quality of patient care
and on program costs, information regarding whether the drug is subject to clinical abuse
or misuse, and relevant data from the state Medicaid program if such data is available;

(2) the Formulary Committee must review the drug, taking into account medical and
clinical data and the information provided by the commissioner; and

(3) the Formulary Committee must hold a public forum and receive public comment for
an additional 15 days.

The commissioner must provide a 15-day notice period before implementing the prior
authorization.

(c) Except as provided in subdivision 13j, prior authorization shall not be required or
utilized for any atypical antipsychotic drug prescribed for the treatment of mental illness
if:

(1) there is no generically equivalent drug available; and

(2) the drug was initially prescribed for the recipient prior to July 1, 2003; or

(3) the drug is part of the recipient's current course of treatment.

This paragraph applies to any multistate preferred drug list or supplemental drug rebate
program established or administered by the commissioner. Prior authorization shall
automatically be granted for 60 days for brand name drugs prescribed for treatment of mental
illness within 60 days of when a generically equivalent drug becomes available, provided
that the brand name drug was part of the recipient's course of treatment at the time the
generically equivalent drug became available.

(d) Prior authorization must not be required for liquid methadone if only one version of
liquid methadone is available. If more than one version of liquid methadone is available,
the commissioner shall ensure that at least one version of liquid methadone is available
without prior authorization.

(e) Prior authorization may be required for an oral liquid form of a drug, except as
described in paragraph (d). A prior authorization request under this paragraph must be
automatically approved within 24 hours if the drug is being prescribed for a Food and Drug
Administration-approved condition for a patient who utilizes an enteral tube for feedings
or medication administration, even if the patient has current or prior claims for pills for that
condition. If more than one version of the oral liquid form of a drug is available, the
commissioner may select the version that is able to be approved for a Food and Drug
Administration-approved condition for a patient who utilizes an enteral tube for feedings
or medication administration. This paragraph applies to any multistate preferred drug list
or supplemental drug rebate program established or administered by the commissioner. The
commissioner shall design and implement a streamlined prior authorization form for patients
who utilize an enteral tube for feedings or medication administration and are prescribed an
oral liquid form of a drug. The commissioner may require prior authorization for brand
name drugs whenever a generically equivalent product is available, even if the prescriber
specifically indicates "dispense as written-brand necessary" on the prescription as required
by section 151.21, subdivision 2.

(f) Notwithstanding this subdivision, the commissioner may automatically require prior
authorization, for a period not to exceed 180 days, for any drug that is approved by the
United States Food and Drug Administration on or after July 1, 2005. The 180-day period
begins no later than the first day that a drug is available for shipment to pharmacies within
the state. The Formulary Committee shall recommend to the commissioner general criteria
to be used for the prior authorization of the drugs, but the committee is not required to
review each individual drug. In order to continue prior authorizations for a drug after the
180-day period has expired, the commissioner must follow the provisions of this subdivision.

(g) Prior authorization under this subdivision shall comply with section 62Q.184.

(h) Any step therapy protocol requirements established by the commissioner must comply
with deleted text begin section deleted text end new text begin sections new text end 62Q.1841 new text begin and 62Q.546. The commissioner must apply the step therapy
requirements of sections 62Q.1841 and 62Q.546 to service delivery under fee-for-service new text end .

(i) Notwithstanding any law to the contrary, prior authorization or step therapy shall not
be required or utilized for any class of drugs that is approved by the United States Food and
Drug Administration for the treatment or prevention of HIV and AIDS.

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2026.
new text end