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ARIZONA STATE SENATE
Fifty-Seventh Legislature, Second Regular Session
AHCCCS; antipsychotic drugs; authorization
Purpose
Effective January 1, 2027, prohibits the Arizona Health Care Cost Containment System (AHCCCS) and its contractors from requiring prior authorization for prescription antipsychotic drugs and limits any step therapy protocols to no more than two distinct prescription antipsychotic drugs.
Background
AHCCCS serves as Arizona's Medicaid agency, which offers Arizona residents access to healthcare programs. AHCCCS contracts with health professionals to provide medically necessary health and medical services to eligible members. Additionally, AHCCCS must contract for a coordinated system of behavioral health services for persons deemed seriously mentally ill, including screening and intake, case management, treatment planning family involvement and a continuum of care (A.R.S. §§ 36-2901 and 36-3407).
Seriously
mentally ill means persons who, as a result of a mental disorder, exhibit
emotional or behavioral functioning that is so impaired as to interfere
substantially with their capacity to remain in the community without supportive
treatment or services of a long-term or indefinite duration. In these persons,
mental disability is severe and persistent, resulting in a
long-term limitation of their functional capacities for primary activities of
daily living such as interpersonal relationships, homemaking, self-care,
employment and recreation (A.R.S.
§ 36-550)
Step therapy
protocol is a protocol or program that establishes the specific sequence in
which prescription drugs that are for a specified medical condition and that
are medically necessary for a particular patient are covered by a health care
insurer under a health care plan (A.R.S.
§ 20-3651).
If there is a cost associated with limiting AHCCCS's ability to require prior authorization and step therapy protocols for antipsychotic drugs, there may be a fiscal impact to the state General Fund.
Provisions
1. Specifies that, before providing coverage of a prescription antipsychotic drug approved by the U.S. Food and Drug Administration to a member who is at least 18 years old with a serious mental illness, AHCCCS and its contractors:
a) may not impose a prior authorization requirement or other process that conditions, delays or denies the delivery of the drug to the member by applying predetermined criteria by AHCCCS or its contractor for covered prescription drugs, except as otherwise outlined; and
b) may impose a process, including a step therapy protocol, requiring the member to show a failure to successfully respond to up to two distinct prescription antipsychotic drugs.
2. Requires AHCCCS and its contractors to allow a member, or the member's health care provider, to bypass a step therapy protocol by submitting documentation that the member failed to successfully respond to two distinct prescription antipsychotic drugs on the member's current or previous health benefit plan.
3. Requires any step therapy protocol or other process administered to:
a) be adjudicated electronically and in real time; and
b) consider a member to have tried two prescription antipsychotic drugs if the member has two paid claims for two distinct preferred antipsychotic drugs.
4. Specifies that the antipsychotic drug coverage requirements:
a) only apply to a prescription antipsychotic drug whose use is supported by peer-reviewed, evidence-based literature;
b) apply to prescription drug coverage that is paid either on a fee-for-service basis or through a prepaid capitated health services contract under AHCCCS;
c) do not prohibit AHCCCS from contracting with a managed care organization for pharmaceutical services offered under AHCCCS if the contract complies with the outlined requirements;
d) do not prohibit AHCCCS from prohibiting or discourage the use of a generic drug; and
e) do not prevent AHCCCS from performing a drug utilization review that is necessary for patient safety or to ensure that the prescribed use is for a medically accepted indication.
5.
Defines failure to successfully respond as a determination, based
on clinically appropriate guidelines, that a patient has failed on a
medication, including a lack of efficacy during a
six-week medication trial, an allergic reaction, intolerable side effects,
significant drug-to-drug interactions or a known interacting genetic
polymorphism that prevents safe preferred medication dosing as attested to by
the patient's health care provider.
6. Defines terms.
7. Becomes effective on January 1, 2027.
Prepared by Senate Research
February 9, 2026
MM/SDR/hk