{"data":{"id":"us-ky/krs-205.536","jurisdiction":"us-ky","citation":"KRS 205.536","heading":"Utilization review -- Prohibition against prospective or concurrent review","body":"of prescription drug for alcohol or opioid use disorder.            (Effective until\nJanuary 1, 2028)\n(1) A Medicaid managed care organization shall have a utilization rev iew plan, as\ndefined in KRS 304.17A -600, that meets the requirements established in 42 C.F.R.\npts. 431, 438, and 456. If the Medicaid managed care organization utilizes a private\nreview agent, as defined in KRS 304.17A -600, the agent shall comply with all\napplicable requirements of KRS 304.17A-600 to 304.17A-633.\n(2) In conducting utilization reviews for Medicaid benefits, each Medicaid managed\ncare organization shall use the medical necessity criteria selected by the Department\nof Insurance pursuant to KRS  304.38-240, for making determinations of medical\nnecessity and clinical appropriateness pursuant to the utilization review plan\nrequired by subsection (1) of this section.\n(3) To the extent consistent with the federal regulations referenced in subsection (1) of\nthis section, the Department for Medicaid Services or any managed care\norganization contracted to provide Medicaid benefits pursuant to KRS Chapter 205\nshall not require or conduct a prospective or concurrent review, as defined in KRS\n304.17A-600, for a prescription drug:\n(a) That:\n1. Is used in the treatment of alcohol or opioid use disorder; and\n2. Contains Methadone, Buprenorphine, an opioid antagonist, or\nNaltrexone; or\n(b) That was approved before January 1, 2022, by the United States Food and\nDrug Administration for the mitigation of opioid withdrawal symptoms.\nEffective: July 15, 2024","path":["KRS Chapter 205"],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=55333","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:52:03Z","sha256":"2428e1b429dcde1a785fea49997ca3279737971f0e0c8e29caf3174dd202126e","source_id":"us-ky","stale":false,"prev":"us-ky/krs-205.5357","next":"us-ky/krs-205.5361"},"notice":"GroundRules: Original legal text. Not legal advice."}