49-20-417.  Insurance coverage for amino acid-based formula.

(1)  As used in this section:

Terms Used In Utah Code 49-20-417

(a)  “Amino acid-based elemental formula” means a nutrition formula:

(i)  made from individual nonallergenic amino acids that are broken down to enhance absorption and digestion; and

(ii)  designed for individuals who have a dysfunctional or shortened gastrointestinal tract and are unable to tolerate and absorb whole foods or formulas composed of whole proteins, fats, or carbohydrates.

(b)  “Eosinophilic gastrointestinal disorder” means a disorder characterized by having above normal amounts of eosinophils in one or more specific places anywhere in the digestive system.

(c)  “Food protein-induced enterocolitis syndrome” means a disorder characterized by an abnormal immune response to an ingested food, resulting in gastrointestinal inflammation.

(d)  “Health insurer” means an insurer, as defined in Subsection 31A-22-634(1).

(e)  “Order” means to communicate orally, in writing, or by electronic means.

(f)  “Pharmacy” means a pharmacy licensed under Title 58, Chapter 17b, Pharmacy Practice Act.

(g)  “Physician” means an individual who is licensed under Title 58, Chapter 67, Utah Medical Practice Act, or Title 58, Chapter 68, Utah Osteopathic Medical Practice Act.

(h)  “Program” means the eosinophilic gastrointestinal disorder program created in Subsection (2).

(i)  “Severe protein allergic conditions” includes:

(i)  eosinophilic esophagitis;

(ii)  eosinophilic gastritis;

(iii)  eosinophilic gastroenteritis;

(iv)  eosinophilic enteritis;

(v)  eosinophilic colitis; or

(vi)  food protein-induced enterocolitis syndrome.

(j)  “Short bowel syndrome” means malabsorption of nutrients resulting from anatomical or functional loss of a significant length of the small intestine.

(2)  Beginning plan year 2017-18 and ending plan year 2019-20, the Public Employees’ Benefit and Insurance Program shall offer a 3-year pilot program within the state risk pool that provides coverage for the use of an amino acid-based elemental formula, regardless of the delivery method of the formula, for the diagnosis or treatment of an eosinophilic gastrointestinal disorder, food protein-induced enterocolitis syndrome, severe protein allergic condition, or short bowel syndrome in the traditional and Star plans.

(3)  Coverage offered under Subsection (2) applies to an amino acid-based elemental formula if:

(a)  the formula is ordered for the enrollee by a physician;

(b)  the physician indicates in the order that the formula is medically necessary; and

(c)  the insured obtains the formula from a pharmacy.

(4)  Coverage offered under Subsection (2) may not include cost-sharing provisions, including deductibles, copayments, co-insurance, and out-of-pocket limits, or a durational limit, that are less favorable to the insured than the cost-sharing provisions and durational limits applied by the health benefit plan to prescription drugs.

(5)  The purpose of the program is to study the efficacy of providing coverage for the use of an amino acid-based elemental formula and is not a mandate for coverage of an amino acid-based elemental formula within the health plans offered by the Public Employees’ Benefit and Insurance Program.

(6)  Under Section 63J-1-603 of the Utah Code, the Legislature intends that the cost of the program shall be paid for from funds above the minimum recommended level in the public employees’ state risk pool reserve.

Enacted by Chapter 349, 2017 General Session

Technically renumbered to avoid duplication of section number also enacted in HB154, Chapter 241.

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