MISSISSIPPI LEGISLATURE

1998 Regular Session

To: Public Health and Welfare

By: Senator(s) Nunnelee

AN ACT TO CREATE NEW SECTIONS 83-41-314 AND 83-41-410, MISSISSIPPI CODE OF 1972, TO REQUIRE HEALTH MAINTENANCE ORGANIZATION AND MANAGED CARE PLANS TO PROVIDE COVERAGE FOR CERTAIN DRUGS, TO ESTABLISH DRUG UTILIZATION REVIEW PROGRAMS AND TO PROVIDE ACCESS TO PERSONNEL FLUENT IN LANGUAGES OTHER THAN ENGLISH WHEN NECESSARY; AND FOR RELATED PURPOSES. 

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

SECTION 1. The following shall be codified as Section 83-41-314, Mississippi Code of 1972:

83-41-314. (1) The health maintenance organization shall provide access to personnel fluent in languages other than English, to the greatest extent possible, when a significant number of enrollees speaks a first language other than English.

(2) (a) The organization shall provide coverage for all FDA-approved drugs and devices whether or not that drug or device has been approved for the specific treatment or condition so long as the primary care practitioner or other medical specialist treating the enrollee determines the drug or device is medically necessary and appropriate for the enrollee's condition.

(b) The organization shall establish and operate a drug utilization review program with ongoing periodic examinations of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees. The drug utilization review program shall include the following:

(i) Clinically relevant criteria and standards for drug therapy;

(ii) Nonproprietary criteria and standards, developed and revised through an open, professional consensus process; and

(iii) Interventions which focus on improving therapeutic outcomes.

(c) The organization shall provide an educational outreach program as part of the drug utilization review program. The outreach program shall be directed to enrollees, pharmacists and other health care professionals and shall emphasize the appropriate use of prescription drugs.

(d) Prospective review of drug therapy may deny services only in cases of enrollee ineligibility, coverage limitations or fraud.

(e) The prescribing health care professional shall determine the appropriate drug therapy for the enrollee; no substitutions shall be made without the direct approval of the prescriber.

SECTION 2. The following shall be codified as Section 83-41-410, Mississippi Code of 1972:

83-41-410. (1) The managed care plan shall provide access to personnel fluent in languages other than English, to the greatest extent possible, when a significant number of enrollees speaks a first language other than English.

(2) (a) The plan shall provide coverage for all FDA-approved drugs and devices whether or not that drug or device has been approved for the specific treatment or condition so long as the primary care practitioner or other medical specialist treating the enrollee determines the drug or device is medically necessary and appropriate for the enrollee's condition.

(b) The plan shall establish and operate a drug utilization review program with ongoing periodic examinations of data on outpatient prescription drugs to ensure quality therapeutic outcomes for enrollees. The drug utilization review program shall include the following:

(i) Clinically relevant criteria and standards for drug therapy;

(ii) Nonproprietary criteria and standards, developed and revised through an open, professional consensus process; and

(iii) Interventions which focus on improving therapeutic outcomes.

(c) The plan shall provide an educational outreach program as part of the drug utilization review program. The outreach program shall be directed to enrollees, pharmacists and other health care professionals and shall emphasize the appropriate use of prescription drugs.

(d) Prospective review of drug therapy may deny services only in cases of enrollee ineligibility, coverage limitations or fraud.

(e) The prescribing health care professional shall determine the appropriate drug therapy for the enrollee; no substitutions shall be made without the direct approval of the prescriber.

SECTION 3. This act shall take effect and be in force from and after July 1, 1998.