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HB 4815

Human services: medical services; coverage for treatment of menopause and perimenopause symptoms and waiver of prior authorization for prescription drugs or treatments for menopause and perimenopause symptoms; require. Amends sec. 109h of 1939 PA 280 (MCL 400.109h) & adds sec. 109t.

2025-2026 Regular Session Introduced by Julie Brixie and 21 co-sponsors

Expands Michigan Medicaid coverage to all medically necessary menopause/perimenopause care, including HRT, and removes prior authorization for such therapies to speed access.

bill electronically reproduced 08/26/2025
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Bill Summary · HB 4815

Summary: House Bill 4815 (HB 4815)

Proposed legislation to expand coverage and remove prior authorization barriers for menopause and perimenopause treatment under Michigan’s medical assistance program.

Purpose and intent

  • Ensure Medicaid/Medical Assistance program coverage for all medically necessary care or treatment related to menopause and perimenopause, including hormone replacement therapy (HRT) and FDA-approved treatments.
  • Remove or waive prior authorization requirements (PA) for menopause/perimenopause therapies, and limit PA for many other essential medications under a proposed framework.

Key provisions

1) Prior authorization protections for prescribed drugs (Sec. 109h)

  • If the department develops a PA process for prescription drugs under the medical assistance program, it shall not require PA for:
    • (a) Central nervous system (CNS) drugs classified as anticonvulsants, antidepressants, antipsychotics, or noncontrolled anti-anxiety drugs, as listed in standard medical references.
    • (b) Drugs cross-indicated for a CNS drug described in (a) per standard references.
    • (c) Drugs recognized as effective for conditions in the DSM (including substance use disorders) unless a controlled substance is involved; PA for controlled substances cannot be denied unless usage is not consistent with licensed indications or accepted medical practice.
    • (d) Drugs used to prevent or treat HIV infection or HIV/AIDS complications.
    • (e) Drugs used to treat cancer, organ replacement therapy, epilepsy/seizure disorders, or opioid withdrawal symptom management.
    • (f) Any medication prescribed or administered to treat symptoms of menopause and perimenopause (e.g., HRT or FDA-approved therapies).
  • This provision applies to drugs supplied under department contracts with health maintenance organizations (HMOs) and allows, but does not prohibit, contracting with managed care organizations (MCOs as long as compliant).

2) Coverage for menopause/perimenopause care (Sec. 109t)

  • The department must provide coverage under the medical assistance program for any medically necessary care or treatment for menopause and perimenopause, including HRT and FDA-approved therapies.
  • No step therapy or fail-first requirements may be applied to medications used for hormone replacement therapy to treat menopause/perimenopause symptoms.

Definitions (Sec. 109t)

  • Menopause: Permanent cessation of menstruation due to loss of ovarian function.
  • Perimenopause: Transitional period near the end of reproductive years or at menopause onset.

Who is affected

  • Michigan Medicaid beneficiaries and others receiving medical assistance for menopause/perimenopause treatment.
  • Prescribers and pharmacies dispensing menopause-related therapies.
  • Department of Health and Human Services, including its contracts with HMOs/MCOs and agents handling prior authorization.

Procedural and timeline aspects

  • Introduced and electronically reproduced: August 26, 2025.
  • Introduced by Rep. Morgan Foreman and others; referred to the Committee on Insurance.
  • Legislative actions show activity earlier in 2025 (first-time readings and referrals) but the current status reflects committee referral for HB 4815.

Potential impact and considerations

  • Access: Likely improves access to menopause/perimenopause treatments by eliminating PA barriers and guaranteeing coverage for medically necessary care.
  • Administrative: Reduces delays associated with prior authorizations for menopause therapies; maintains PA for many other drug categories per the bill’s framework.
  • Costs: Potential near-term cost increases for Medicaid/MA programs due to broader coverage of menopause therapies; exact fiscal impact would depend on uptake and pricing.
  • Policy alignment: Builds on existing MA provisions and expands protections to a broader patient population undergoing menopause-related treatment.

If you’d like, I can provide a side-by-side comparison with current law or highlight potential fiscal impact estimates when available.

Compiled from official sources — confirm details with the bill’s official record.

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