BILL NUMBER: AB 1814	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 21, 2014
	AMENDED IN ASSEMBLY  MARCH 28, 2014

INTRODUCED BY   Assembly Member Waldron

                        FEBRUARY 18, 2014

   An act to add Section 14133.06 to the Welfare and Institutions
Code, relating to Medi-Cal.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 1814, as amended, Waldron. Prescriber Prevails Act.
   Existing law provides for the Medi-Cal program, which is
administered by the State Department of Health Care Services, under
which qualified low-income individuals receive health care services.
The Medi-Cal program is, in part, governed and funded by federal
Medicaid Program provisions. Existing law specifies the benefits
provided pursuant to the program, including the purchase of
prescribed drugs which are covered subject to utilization controls.
Utilization controls include a requirement that the treatment
provider obtain prior authorization for providing medical treatment,
as specified.
   This bill would, to the extent permitted by federal law, provide
that drugs in specified therapeutic drug classes that are prescribed
by a Medi-Cal beneficiary's treating provider are covered Medi-Cal
benefits. The bill would require, except as specified, that a
Medi-Cal managed care plan cover the drug upon demonstration by the
provider that the drug is medically necessary and consistent with
federal rules and regulations for labeling and use, as specified.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: no.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  This act shall be known, and may be cited as, the
Prescriber Prevails Act.
  SEC. 2.  Section 14133.06 is added to the Welfare and Institutions
Code, to read:
   14133.06.  (a) It is the intent of the Legislature in enacting
this section that a prescriber's reasonable, professional judgment
prevails for the therapeutic drug classes specified in subdivision
(b) that are not on managed care plan formularies or have prior
authorization requirements.
   (b) To the extent permitted by federal law, if a drug in any of
the following therapeutic drug classes is prescribed by a Medi-Cal
beneficiary's treating provider, that drug shall be covered under the
Medi-Cal program:
   (1) Antiretroviral drugs for HIV/AIDS.
   (2) Drugs used to treat hepatitis C.
   (3) Antipsychotics.
   (4) Antirejection drugs.
   (5) Drugs used to treat seizures or epilepsy.
   (c) Except as provided in subdivision (d), and notwithstanding the
establishment of a statewide outpatient drug formulary, a Medi-Cal
managed care plan shall cover a drug specified in subdivision (b),
regardless of whether the drug is on the plan's formulary, if, upon
demonstration by the provider that the drug, in his or her
reasonable, professional judgment, is medically necessary and
consistent with the federal Food and Drug Administration's labeling
and use rules and regulations, as supported in at least one of the
official compendia, as defined in Section 1927(g)(1)(B)(i) of the
federal Social Security Act (42 U.S.C. Sec. 1396r-8(g)(1)(B)(i)).

   (1) Medi-Cal managed care plans shall continue to develop
formularies and may also administer prior authorization programs for
the drugs specified in subdivision (b). Providers prescribing those
drugs may be required to provide the plans with requested information
or clinical documentation to support prior authorization requests.
The plans may continue to provide a temporary three-day supply of
medication when medically necessary.  
   (2) Consistent with federal law, if a Medi-Cal managed care plan
is unable to complete a prior authorization due to missing
information or because the prescriber's reasonable, professional
judgment has not been adequately demonstrated, as required under this
subdivision, the plan shall issue a notice of action to the provider
and the beneficiary. The plan shall include in the notice of action
a description of the information that is required from the provider
or the beneficiary in order for the plan to complete the
authorization, and the beneficiary's rights regarding appeal and fair
hearing options. 
   (d) (1) If a Medi-Cal managed care plan chooses not to cover the
drugs described in subdivision (b), the drugs shall be carved out of
that plan and covered on a fee-for-service basis.
   (2) If a drug is carved out of a Medi-Cal managed care plan as
described in paragraph (1), the plan's contracted rate shall be
reduced accordingly.