BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 1826
A
AUTHOR: Huffman and Feuer
B
AMENDED: May 28, 2010
HEARING DATE: June 30, 2010
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CONSULTANT:
8
Chan-Sawin/cjt
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6
SUBJECT
Health care coverage: prescriptions
SUMMARY
Requires a health care service plan (health plan) or health
insurer that covers outpatient prescription drug benefits
to provide coverage for a drug that has been prescribed for
the treatment of pain. Prohibits the health plan or
insurer from requiring the subscriber or enrollee to first
use an alternative prescription drug or over-the-counter
drug, as specified.
CHANGES TO EXISTING LAW
Existing federal law:
Defines, under the federal health reform law, the Patient
Protection and Affordable Care Act (PPACA), a list of
"essential health benefits package," including prescription
drug coverage, which health insurance coverage and group
health plans must provide, beginning in 2014.
Existing law:
Provides for the regulation of health plans and insurers by
the Department of Managed Health Care (DMHC) and the
Continued---
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California Department of Insurance (CDI), respectively.
Prohibits health plans and insurers that cover prescription
drugs from limiting or excluding coverage for a drug on the
basis that the drug is prescribed for a use different from
the use for which the drug has been approved by the federal
Food and Drug Administration (FDA), provided that specified
conditions have been met (including that the drug is
prescribed by a participating licensed health care
professional for the treatment of a chronic and seriously
debilitating condition, the drug is medically necessary to
treat that condition, and the drug is on the plan
formulary).
Prohibits health plans covering prescription drug benefits
from limiting, or excluding coverage for a drug for an
enrollee, if the drug was previously approved for coverage
by the plan for a medical condition of the enrollee and the
plan's prescribing provider continues to provide the drug
for the medical condition, provided that it is safe and
effective for treatment. This prohibition does not
preclude the prescribing provider from prescribing another
drug that is covered by the plan and is medically
appropriate, nor does it prohibit generic drug
alternatives.
Requires health plans that provide prescription drug
benefits, and maintain one or more drug formularies, to
provide to the public, upon request, a copy of the most
current list of prescription drugs by major therapeutic
category, with an indication of whether any drugs on the
list are preferred over other listed drugs. Requires plans
that maintain more than one formulary to notify the
requester that a choice of formulary lists is available.
Requires health plans that provide prescription drug
benefits to maintain an expedited process by which
prescribing providers may obtain authorization for a
medically necessary non-formulary drug. Requires any
health plan disapproval to provide the enrollee with the
reasons for the disapproval, and notify the enrollee of the
right to file a grievance if the enrollee objects to the
disapproval, as specified.
Requires the process for authorization of medically
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necessary non-formulary drugs to be described in the health
plan disclosure form.
Requires, in regulations, health plans that cover
outpatient prescription drug benefits to cover all
medically necessary outpatient prescription drugs, as
specified.
This bill:
Requires a health plan or insurer that covers outpatient
prescription drug benefits to provide coverage for a drug
that has been prescribed by a participating licensed health
care provider for the treatment of pain.
Prohibits the health plan or insurer from requiring the
subscriber or enrollee to first use an alternative
prescription drug or over-the-counter drug, but allows the
health plan or insurer to require the subscriber or
enrollee to first use a generically equivalent drug.
Defines "generically equivalent drug" to mean drug products
with the same active chemical ingredients of the same
strength, quantity, and dosage form, and of the same
generic drug name, as determined by the United States
Adopted Names Council and accepted by the federal Food and
Drug Administration, as those drug products having the same
chemical ingredients.
Specifies that nothing in this bill prohibits a health plan
or insurer from charging copayments or deductibles for
prescription drug benefits or imposing limitations on
maximum coverage of prescription drug benefits, as
specified.
Exempts a health plan or health insurance policy purchased
by the California Public Employees' Retirement System
(CalPERS) from the requirements of this bill.
Prohibits this bill from being construed to require
coverage of prescription drugs not in a health plan or
insurer's drug formulary, or to prohibit use of generically
equivalent drugs or generic drug substitutions, as
specified.
FISCAL IMPACT
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According to the Assembly Appropriations Committee
analysis, unknown increased costs to Medi-Cal and the
Healthy Families program in the range of $5 million (50
percent General Fund (GF) and 33 percent GF, respectively).
Although recent amendments address brand name drug cost
pressures, many drugs that remain under patent do not have
generic versions available.
BACKGROUND AND DISCUSSION
According to the author, p ain is a growing national public
health crisis that affects an estimated 76 million people
and has serious economic ramifications , and that c hronic
pain affects more Americans than diabetes, heart disease,
and cancer combined. The author points to a 2006 survey by
the National Center for Health Statistics which states that
the annual cost of chronic pain in the U.S., including
health care expenses, lost income, and lost productivity,
is about $100 billion.
The author states that a troubling and dangerous trend is
the frequent denial of coverage by health plans and
insurers for proven and effective pain treatments. Used as
a cost-saving measure, many health plans and insurers
utilize step therapy or " fail - first " policies , which
require a patient in pain to try an alternative medication,
which in some cases include over-the-counter medications,
before the medication recommended by the physician is
approved.
The author points out that s ome patients are required to
try up to five different medicines before receiving the one
prescribed by their physician and , more often than not, the
alternative drugs have a completely different molecular
structure that can be harmful to patients . While insurers
argue that step therapy is helpful in managing rising drug
costs, the author questions the basic fairness of denying
coverage for a drug that a doctor believes is the most
effective drug for the treatment of someone who is,
oftentimes, in severe, debilitating pain. The author
believes that it is essential that patients in pain receive
the drug treatment prescribed by their physicians and do
not suffer the needless consequences caused by step
therapy.
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The author also asserts that, n ot only is this policy
extremely dangerous to patient health, step therapy can
actually increase the direct cost of health care in the
long run , due to increased emergency room visits, unplanned
doctor's visits, and other health complications. Indirect
costs include lost wages and productivity of both people
with pain and their caregivers. The author points to
findings from a recent study published in the February 2009
issue of the American Journal of Managed Care, that
suggests that step therapy programs may increase overall
health care costs for employers. In the study, researchers
analyzed insurance claims data from 2003 through 2006 for
11,851 people with employer-sponsored health coverage that
incorporated a step therapy protocol for anti-hypertensive
drugs, and compared their use of health care services to a
group of 30,882 anti-hypertensive drug users who did not
participate in a step therapy program. What the
researchers found was that the group of patients treated
for hypertension under the step therapy program had 3.1
percent lower drug costs. But these savings were wiped out
by the increase in hospital admissions and emergency room
visits.
Pain and pain management
According to the American Academy of Pain Management, pain
is a silent epidemic in the United States. An estimated 50
million Americans live with chronic pain caused by disease,
disorder or accident. An additional 25 million people
suffer acute pain resulting from surgery or accident.
Approximately two-thirds of these individuals in pain have
been living with their pain for more than five years. The
most common types of pain include arthritis, lower back,
bone/joint pain, muscle pain, and fibromyalgia. The loss
of productivity and daily activity due to pain is
substantial. According to the American Pain Society, pain
is the second leading cause of medically related work
absenteeism, resulting in more than 50 million lost
workdays annually.
According to a 2006 survey by the National Center for
Health Statistics (NCHS), back pain is the leading cause of
disability in Americans under 45 years old, and more than
26 million Americans between the ages of 20 to64 experience
frequent back pain. The NCHS survey also indicated that
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adults who reported low back pain were three times as
likely to be in poorer health and more than four times as
likely to experience serious psychological distress as
people without low back pain problems. The survey
estimated that the annual cost of chronic pain in the U.S.,
including health care expenses, lost income, and lost
productivity is about $100 billion.
Pain management is a branch of medicine employing an
interdisciplinary approach to easing the suffering and
improving quality of life of those living in pain.
According to the National Institutes of Health (NIH),
common treatments for pain include medication, acupuncture,
local electrical stimulation, brain stimulation, surgery,
psychotherapy, relaxation therapy, biofeedback, and
behavior modification.
Step therapy
In its analysis of this bill (described in detail later in
this analysis), CHBRP defines "fail-first protocols" as the
group of utilization management techniques that would be
prohibited by this bill for pain medications. Step
therapy, also known as "step edit" is one type of
"fail-first" protocol; others include generic substitution
or certain types of prior authorization protocols.
According to a 2001 report by the California HealthCare
Foundation (CHCF) relating to prescription drug coverage
and formulary use in California, step therapy requires
patients and physicians to follow a particular sequence of
drug treatment. In general, a patient must fail to respond
to a recommended first-line therapy before a second- or
third-line medication is prescribed. Typically, this means
that patients will be required to try medications that have
been on the market for a longer period of time and are
usually less expensive than the newer medications available
to treat a specific condition. For example, the CHCF
report suggests that newer inhibitors for the relief of
arthritic pain, such as Celebrex, which are part of a large
class of anti-inflammatory drugs, may be subject to step
therapy requirements.
Generic substitution vs. therapeutic substitution. Generic
substitution refers to the substitution of a brand name
drug for a generic drug that is the chemical equivalent and
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the same dosage of the brand name. Therapeutic
substitution refers to the substitution of one drug with a
chemically different drug within the same therapeutic
category (that is used for the treatment of the same
condition). For example, aspirin is the therapeutic
equivalent of ibuprofen, even though they are chemically
different, as they are used for the treatment of the same
condition.
The California Health Benefits Review Program (CHBRP)
Pursuant to AB 1996 (Thomson), Chapter 795, Statutes of
2002, and SB 1704 (Kuehl), Chapter 684, Statutes of 2006,
the University of California is requested to assess
legislation proposing a mandated benefit or service, or the
repeal of a mandated benefit or service, through the
California Health Benefits Review Program (CHBRP). CHBRP
prepares a written analysis of the public health, medical,
and economic impacts of such measures.
Earlier versions of AB 1826 would have prohibited health
plans and insurers from using all fail-first protocols in
determining outpatient pharmacy benefit coverage for pain
medication. The May 28, 2010 version of this bill would
allow the use of one type of fail-first protocol, generic
substitution, while still prohibiting others. Pursuant to
a letter from CHBRP, dated June 23, 2010, the cost impact
analysis of their April 16, 2010 report would change. The
following are highlights from the CHBRP analysis, including
the applicable changes to the cost impact section as noted
in the June 23, 2010 letter:
Assumptions of the analysis
Prescription medications may be covered as inpatient
medical benefits, and/or through an outpatient
pharmacy benefit, if included in the plan contract or
insurance policy. Some plan contracts or insurance
policies do not include outpatient pharmacy benefits.
The CHBRP report assumes that AB 1826 would not
increase the number of enrollees with an outpatient
prescription drug benefit.
Providers, independent of plan or policy protocols,
may choose to utilize fail-first protocols by
requiring patients to try any number of alternate
medications before prescribing a particular pain
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medication. The report also assumes that provider
prescribing practices would not be subject to AB 1826.
Potential impact of federal health care reform
In March of this year, the President signed the
federal health reform law, the Patient Protection and
Affordable Care Act (PPACA). PPACA would make
significant changes to the California health insurance
market and its regulatory environment. Effective
January 1, 2014, PPACA requires health plans and
insurers to provide coverage for "essential health
benefits," as defined by the Secretary of the
Department of Health and Human Services. Included in
the list of required "essential health benefits" is
coverage of prescription drugs. How these provisions
are implemented in California would depend on
regulations from federal agencies, and statutory and
regulatory actions taken by the state.
PPACA also includes provisions that take effect by
September 2010, which would expand the number of
Californians with insurance, such as requiring
coverage for dependents up to age 26. This would
decrease the number of uninsured and increase the
number of people impacted by this mandate. The CHBRP
analysis does not reflect the impact from
implementation of federal health reform requirements.
Medical effectiveness
Due to the variety of causal conditions and types of
pain (acute and chronic), there is no standard
treatment for pain. Pain treatment varies according
to type, severity, and duration of pain, as well as
the causal condition (if known), patient
co-morbidities, and other factors (e.g., medication
intolerance or patient compliance). Health care
providers use clinical judgment to select among
various pain medications and treatments in efforts to
resolve or control pain for individual patients.
CHBRP found no medical effectiveness literature
addressing the direct effects of fail-first protocols
on resolving or controlling pain.
Of more than 200 prescription medications used to
treat pain, CHBRP reported that 54 were subject to
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fail-first protocols for at least some portion of
enrollees with health insurance subject to this bill.
However, among the 54 medications identified, there is
variation in frequency of medications subject to
fail-first protocols. It is not clear which of these
medications, if any, would be subject to generic
substitution, as allowed for under the most recent
version of the bill.
Additionally, CHBRP found insufficient evidence to
characterize the medical effectiveness of fail-first
protocols for pain medications. Therefore, CHBRP
concluded that the impact of this bill on the medical
effectiveness of pain treatment is unknown, and points
out that the lack of evidence for the effectiveness of
fail-first protocols is not evidence that these
protocols produce either positive or negative health
outcomes.
Impact on coverage
Not all enrollees and insureds have an outpatient
pharmacy benefit. Of those who do, not all of the
pain medications are subject to any fail-first
protocol. For some enrollees, no pain medications are
subject to fail-first protocols. Other enrollees,
depending on the provisions of their plan contracts or
insurance policies, have anywhere between 1 and 38
(out of the 54) pain medications, that is covered by
their outpatient pharmacy benefits, that is subject to
fail-first protocols. It is not clear which of these
medications, if any, would be subject to generic
substitution, as allowed for under the most recent
version of the bill. According to CHBRP, it is
possible that two enrollees with plan contracts from a
single health plan (or policies from a single insurer)
might not have outpatient pharmacy benefits for pain
medications that are subject to the same list of
fail-first protocols - or one of them might not be
subject to any list at all.
About 18.7 million enrollees in DMHC-regulated health
plans or CDI-regulated policies have health insurance
subject to this bill. CHBRP assumed that this bill
would not increase the number of enrollees with an
outpatient pharmacy benefit. CHBRP reports that 18.1
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million, or 97.2 percent, of insured Californians have
outpatient pharmacy benefit coverage. Of these:
8.3 million enrollees (45.5
percent) have pharmacy coverage subject to
fail-first protocols for one or more pain
medications.
9 million enrollees (49.3
percent) have pharmacy coverage that is not
subject to any fail-first protocols and not
affected by this bill.
There are 417,000 enrollees (2.2 percent) who have
generic-only outpatient pharmacy benefit coverage and
would not be affected by this bill.
There are also 521,000 insured Californians (2.8
percent) who do not have outpatient pharmacy coverage
and would not be affected by this bill. CHBRP
confirmed that a portion of beneficiaries in Medi-Cal,
the Healthy Families program, Access for Infants and
Mothers (AIM) Program, and the Major Risk Medical
Insurance Program (MRMIP) have outpatient pharmacy
benefits for pain medication that is subject to some
fail-first protocols. However, as was found to be the
case for privately funded health insurance, the
presence of fail-first protocols varied by plan.
Impact on utilization
According to CHBRP, 610 per 1,000 enrollees receive
prescriptions for identified medications approved by
the FDA and commonly used for pain, both generic and
brand name, over the course of one year. This bill is
not expected to measurably affect this number because
outpatient pharmacy benefit coverage is not expanded
by this bill. AB 1826 is also not expected to result
in an increase in diagnosis or treatment of pain.
This bill is expected to affect the percentage of
filled pain prescriptions that are for generic versus
brand name medications, but the extent is unclear
given the recent amendments.
Impact on cost
In its report released April 16, 2010, CHBRP estimates
total net expenditures (including premiums and
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out-of-pocket expenses) for prescriptions for pain
medications would increase by about $27.7 million or
0.04 percent due to this bill. Total premiums for
private employers are expected to increase by about
$9.3 million or 0.02 percent. Premiums for
individually purchased insurance are expected to
increase by about $2 million or 0.03 percent.
Enrollee out-of-pocket expenses are also estimated to
increase by approximately $3.19 million or 0.05
percent.
The average cost per prescription associated with pain
medications on at least one fail-first protocol list
is projected to increase $30, or 14 percent. The post
mandate increase in average cost per prescription
reflects a decrease in use of generic, and an increase
in use of brand-name, medications. The per-unit cost
of the medications themselves is not expected to
increase.
Medi-Cal expenditures are estimated to increase by
about $8.12 million, or 0.2 percent, and state
expenditures for Healthy Families, AIM, and MRMIP are
estimated to increase by about $2.10 million or 0.2
percent. This is an increase of $0.24 per member per
month (PMPM) for Medi-Cal, Healthy Families, AIM, and
MRMIP.
Expected PMPM increases in other market segments are
as follows: $0.08 PMPM in large-group market
DMHC-regulated plans; $0.11 PMPM in large-group marked
CDI-regulated policies; $0.11 PMPM in small-group
market DMHC-regulated plans; $0.17 PMPM in small-group
market CDI-regulated policies; $0.10 PMPM in
individual market DMHC-regulated plans; and, $0.10
PMPM in individual market CDI-regulated policies.
Per the June 23, 2010 CHBRP update letter, these cost
projections would likely be lower. However, the
extent to which the cost estimates would decrease
would require another analysis, since the underlying
analytic approach would need to be re-assessed.
Specifically, the approach for identifying the number
of medications on fail-first protocol lists, and the
number of enrollees affected, may need to be modified.
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Public health impact
CHBRP reports that, although there is some evidence
that fail-first protocols can lead to lower levels of
patient satisfaction, delays in receiving medications,
and higher rates of unfilled prescriptions, this
research is not generalizable to populations outside
of those studied . Therefore, the public health impact
of this bill is unknown.
Additionally, CHBRP was unable to determine the extent
to which this bill would impact people of different
genders or racial/ethnic groups differentially.
Lastly, CHBRP states that pain conditions are known to
be relevant factors in terms of lost productivity and
associated economic loss through days missed from work
as well as reduced ability to perform tasks at work.
However, no research was identified that assessed the
impact of fail-first protocols for pain medications on
measures of productivity. Therefore, the impact of
this bill on lost productivity and economic loss
associated with conditions requiring the use of pain
medications is unknown.
Arguments in support
The sponsor of this bill, For Grace, writes that this bill
highlights the inadequacies of step therapy because a
patient in pain can tell immediately whether or not a pain
medication is working and should not be forced to stay on
medicine that does not relieve their pain.
Chronic pain advocacy groups, and community and labor
organizations support this bill because it will ensure that
patients have access to the right treatment at the right
time. The American Chronic Pain Association asserts that
treatment decisions should rely on the physician's clinical
expertise, patient's health history, and the best
scientific evidence available, rather than driven by cost.
The Community Life Improvement Program adds that applying
step therapy protocols rigidly to a pain patient is not in
the patient's best interest especially when women are more
likely than men to be under-treated for their pain and
minorities receive even less quality of care. Labor
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groups, such as the American Federation of State, County
and Municipal Employees, point out in support that it is
fundamentally unfair to permit patients to suffer
unnecessary pain in the hopes that a cheaper drug will be
as effective as the medication their physicians actually
prescribe and they argue that, in the long run, there is no
convincing evidence that step therapy actually even saves
money.
Health care professional organizations, such as the
Association of Northern California Oncologists and
California Medical Association, writes in support of this
bill, asserting that AB 1826 will remove roadblocks and
obstacles that prevent patients with pain from receiving
the medically necessary, reasonable, and most appropriate
pain management and treatment options prescribed by their
physicians, who best understand their patients' health
needs. The California Nurses Association states that
requiring patients to fail first may cause unnecessary
delays in access and subsequently compromise patient care
and increase health care costs for employers.
Pharmaceutical and biotechnology companies, and related
associations, such as the California Healthcare Institute
(CHI) and BIOCOM, write in support, stating that the health
care provider should have access to a full range of
therapeutic options to use as they see fit for that
particular patients. CHI states that their member company
treatments are only effective when patients have access to
them. AstraZeneca asserts that physicians should not have
their hands tied with cost containment techniques when it
comes to making the best possible decision for the patient.
Arguments in opposition
The Department of Managed Health Care opposes this bill,
stating that step therapy, when used appropriately by
providers, should continue to be one of the many effective
tools for ensuring the delivery of quality and
cost-effective health care services. DMHC also points out
that federal health care reform incorporates prescription
drugs under its essential benefits requirement, but since
there is no guidance from the federal government regarding
the scope of these benefits, it is premature to consider AB
1826.
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Many health plans and insurers write in opposition to this
bill. America's Health Insurance Plans argues that this
bill not only fails to further advance the goals of patient
safety and quality of care, but threatens the ability of
health plans to ensure their enrollees are prescribed the
correct course of treatment in clinically appropriate
amounts. The California Association of Health Plans writes
in opposition that requiring coverage for any prescribed
pill or other medication for pain is highly questionable,
particularly when the ability of a plan to encourage safe
alternatives is also eliminated. The Association of
California Life and Health Insurance Companies points out
that providers and patients are already protected under
current law, as they may file grievances through the
Independent Medical Review System, including through an
expedited appeals process if there is an imminent and
serious threat to the health of the insured, which includes
suffering from serious pain. Health Net asserts that
requiring plans and insurers to cover any pain medication
prescribed by a provider, without regard to guidelines,
will drive up health care costs. Molina Healthcare of
California points to a recent article in the Journal of the
American Medical Association that called for physicians to
be critical of new drugs and pointed out that prescribing
generic medication, which have a longer track record
compared to new drugs, have safety benefits beyond cost.
Pharmacy benefit managers (PBMs), including Medco Health
Solutions, Inc., and Express Scripts, Inc., maintain that
implementation of a well-designed step therapy program
ensures that patients receive appropriate medications in a
cost effective manner, while reducing waste, error and
unnecessary drug use. PBMs contend that prohibiting the
use of this key drug management tool for pain medications
will make it more difficult to manage the costs of
prescription drugs and increase premiums and copayments for
all patients.
The California Chamber of Commerce opposes the bill because
they say it eliminates current cost controls and unravels
consumer protections by eliminating the practice of step
therapy, the practice of beginning drug therapy with the
most cost-effective and safest medication, and progressing
to other more costly or risky medications, as necessary.
The California Association of Joint Powers Authorities
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objects to the exemption provided to CalPERS from complying
with this bill because it ignores that all local public
entities will be forced to absorb the prescription coverage
cost increases resulting from this bill.
Prior legislation
AB 1144 (Price) of 2009 would have required health plans
and insurers to report specified information relating to
chronic pain medication management requirements for their
enrollees or insureds to DMHC and CDI, respectively.
Failed passage in the Assembly Appropriations Committee.
AB 974 (Gallegos), Chapter 68, Statutes of 1998, prohibits
health plans that cover prescription drugs from limiting or
excluding coverage for a drug that had previously been
approved by the plan.
SB 625 (Rosenthal), Chapter 69, Statutes of 1998, requires
health plans that cover prescription drugs and that have
one or more formularies to publicly disclose, upon request,
a copy of the current list of prescription drugs that
includes specified information and to maintain an expedited
prior authorization process for medically necessary
non-formulary prescription drugs, and clarifies the content
of the notice, including grievance information, that is
required to be sent to an enrollee when a prior
authorization request is denied by the plan.
AB 1985 (Speier), Chapter 1268, Statutes of 1992, prohibits
health plans and insurers that provide coverage for
prescription drugs, from limiting or excluding coverage for
a drug on the basis that it is prescribed for an off-label
use, if specified criteria are met.
PRIOR ACTIONS
Assembly Health: 11-6
Assembly Appropriations: 12-0
Assembly Floor: 45-26
COMMENTS
1.Bill could require plans and insurers to cover medications
in situations that are contrary to established guidelines.
As currently written, the bill could require plans and
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insurers to cover any prescribed pain medication. There
may be cases where a prescribing physician may have good
reason why certain pain medication is necessary for a
specific patient. Should the bill be amended to ensure
that the physician's intention is clear when they prescribe
pain medications in a way that is at odds with established
guidelines?
2.Is the exemption for CalPERS appropriate? This bill is
intended to address barriers that patients in pain may face
while trying to access pain medication. However, there is
nothing to suggest that enrollees and insureds in CalPERS
plans and policies would not be similarly affected.
POSITIONS
Support: For Grace (sponsor)
American Academy of Pain Medicine
American Chronic Pain Association
American Federation of State, County and
Municipal Employees, AFL-CIO
American Pain Foundation
Arthritis Care Center, Inc.
Arthritis Foundation
Association of California Neurologists
Association of Northern California Oncologists
AstraZeneca
Bay Area Women's Health Advocacy Council
BIOCOM
California Academy of Pain Medicine
California Academy of Physician Assistants
California Alliance for Retired Americans
California Conference Board of the Amalgamated
Transit Union
California Conference of Machinists
California Healthcare Institute
California Medical Association
California NeuroAlliance
California Nurses Association
California Orthopedic Association
California Professional Firefighters
California Society of Dermatology and Dermatologic
Surgery
Community Life Improvement Program
Congress of California Seniors
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Consumer Attorneys of California
Consumer Federation of California
Engineers and Scientists of California, IFPTE Local
20
Familia Unida Living with Multiple Sclerosis
Foundation for Peripheral Neuropathy
Global Healthy Living Foundation
Healthy African American Families
International Longshore and Warehouse Union
Intractable Pain Patients United
Jockeys' Guild
Latina Breast Cancer Agency
Marin County Pharmaceutical Association (MCPhA)
Medical Oncology Association of Southern California
(MOSAC)
Metropolitan Pain Management Consultants, Inc.
National Kidney Foundation
National Multiple Sclerosis Society
Osteopathic Physicians and Surgeons
Pharmacists Planning Service, Inc. (PPSI)
Power of Pain Foundation
Professional and Technical Engineers, IFPTE Local
21
Southern California Cancer Pain Initiative
United Food and Commercial Workers Region 8 States
Council
UNITE-HERE
United Leukodystrophy Foundation
12 individuals
Oppose: America's Health Insurance Plans (AHIP)
Anthem Blue Cross
Association of California Life and Health Insurance
Companies
Blue Shield of California
California Association of Health Plans
California Association of Joint Powers Authorities
(CAJPA)
California Chamber of Commerce (CalChamber)
Community Health Group
CSAC Excess Insurance Authority
Department of Managed Health Care
Express Scripts, Inc.
Health Net
Medco Health Solutions, Inc.
STAFF ANALYSIS OF ASSEMBLY BILL 1826 (Huffman, Feuer) Page
18
Molina Health Cares
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