Indiana § 12-15-35-51 - Advisory committee; duties; report

§ 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 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.

(i) The advisory committee shall select one (1) member of the advisory committee to serve as representation on the therapeutics committee established by section 20.5 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; P.L.213-2025, SEC.115.

IC 12-15-35.5Chapter 35.5. Prescription Drugs

12-15-35.5-1Applicability 12-15-35.5-2"Cross-indicated drug" defined 12-15-35.5-2.5Repealed 12-15-35.5-2.6"Waste" 12-15-35.5-3Establishment of prior authorization requirements 12-15-35.5-4Prior authorization requirement parameters 12-15-35.5-5Prior authorization procedures 12-15-35.5-6Publication of prior authorization decision 12-15-35.5-7Limitations on drug refills 12-15-35.5-7.5Reimbursement for methadone when prescribed for pain; requirements 12-15-35.5-8Restriction of mental health drugs for individuals less than 18 years of age 12-15-35.5-9Reimbursement for drugs indicated only for addiction treatment 12-15-35.5-10Determination of eligibility of certain outpatient prescription drugs for rebates

IC 12-15-35.5-1Applicability 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.

IC 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.

IC 12-15-35.5-2.5RepealedAs added by P.L.107-2002, SEC.23. Amended by P.L.184-2003, SEC.10. Repealed by P.L.213-2025, SEC.116.

IC 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.

IC 12-15-35.5-3Establishment of prior authorization requirements Sec. 3. The office may establish prior authorization requirements for drugs covered under a program described in section 1 of this chapter.

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; P.L.213-2025, SEC.117.

IC 12-15-35.5-4Prior 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.

IC 12-15-35.5-5Prior 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.

IC 12-15-35.5-6Publication 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.

IC 12-15-35.5-7Limitations on drug refills Sec. 7. (a) Subject to subsection (b), the office may place limits on quantities dispensed or the frequency of refills for any covered drug as required by law or for the purpose of:

(1) preventing fraud, abuse, or waste;

(2) preventing overutilization, inappropriate utilization, or inappropriate prescription practices that are contrary to:

(A) clinical quality and patient safety; and

(B) accepted clinical practice for the diagnosis and treatment of mental illness and the considerations specified in subsection (h); or

(3) implementing a disease management program.

(b) Before implementing a limit described in subsection (a), the office shall:

(1) consider quality of care and the best interests of Medicaid recipients;

(2) seek the advice of the drug utilization review board, established by IC 12-15-35-19, at a public meeting of the board; and

(3) publish a provider bulletin that complies with the requirements of IC 12-15-13-6.

As added by P.L.6-2002, SEC.4. Amended by P.L.184-2003, SEC.11; P.L.101-2005, SEC.7; P.L.8-2007, SEC.1; P.L.36-2009, SEC.3; P.L.229-2011, SEC.145; P.L.7-2015, SEC.35; P.L.210-2015, SEC.51; P.L.213-2025, SEC.118.

IC 12-15-35.5-7.5Reimbursement 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.

IC 12-15-35.5-8Restriction 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.

IC 12-15-35.5-9Reimbursement 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.

IC 12-15-35.5-10Determination of eligibility of certain outpatient prescription drugs for rebates Sec. 10. (a) As used in this section, "340B covered entity" means an entity authorized to participate in the federal 340B Drug Pricing Program under Section 340B(a)(4) of the federal Public Health Service Act (42 U.S.C. 256b(a)(4)) and includes any pharmacy under contract with the entity to dispense drugs on behalf of the entity.

(b) The office of the secretary shall determine whether outpatient prescription drugs prescribed to Medicaid recipients from a 340B covered entity are eligible for rebates under the 340B drug pricing program or whether those prescriptions shall be subject to rebates under the Medicaid drug rebate program under Section 1927 of the federal Social Security Act.

(c) The office of the secretary may adopt rules under IC 4-22-2 and any written policies or procedures as necessary to implement this section.

As added by P.L.213-2025, SEC.119.

IC 12-15-36Chapter 36. Payments for Special Services

12-15-36-1Application of chapter 12-15-36-2"Chronically medically dependent" defined 12-15-36-3"Special skilled services" defined 12-15-36-4Payment rate; establishment under federal law 12-15-36-5Payment standards; costs included 12-15-36-6Implementation of chapter 12-15-36-7Approval of more than 100 beds; necessity of agreement