BILL NUMBER: AB 68	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  APRIL 30, 2015
	AMENDED IN ASSEMBLY  MARCH 26, 2015

INTRODUCED BY   Assembly Member Waldron

                        DECEMBER 18, 2014

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


	LEGISLATIVE COUNSEL'S DIGEST


   AB 68, as amended, Waldron. Medi-Cal.
   Existing law establishes the Medi-Cal program, which is
administered by the State Department of Health Care Services, and
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. Covered benefits under the
Medi-Cal program include the purchase of prescribed drugs, subject to
the Medi-Cal List of Contract Drugs and utilization controls.
   This bill, which would be known as the Patient Access to
Prescribed Epilepsy Treatments Act, would require, to the extent
permitted by federal law, that any drug in the seizure or epilepsy
therapeutic drug class would be a covered benefit under the Medi-Cal
program. The bill would require a Medi-Cal managed care plan to
provide coverage for these drugs, regardless of whether the drug is
on the plan's formulary, if the treating provider demonstrates
 that,  that  in his or her reasonable,
professional judgment, the drug is medically necessary  , not on
the Medi-Cal managed care plan formulary,  and consistent with
specified federal rules and  regulations. If the managed care
plan elects not to cover a drug described in the bill, the drug
would be deemed a noncapitated benefit not reimbursed by the managed
care plan, which would be available on a fee-for-service basis, and
the plan's contracted rate would be reduced to reflect the cost to
the state of providing the benefit to the patient, as specified. This
bill would declare the intent of the Legislature that a prescriber's
reasonable, professional judgment prevail in prescribing the drugs
described in the bill to Medi-Cal patients.  
regulations, under which circumstances the beneficiary would be
entitled to an automatic urgent appeal, as defined. 
   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
Patient Access to Prescribed Epilepsy Treatments 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 prevail in prescribing to Medi-Cal patients any drug in the
therapeutic drug class that includes drugs approved by the federal
Food and Drug Administration for use in the treatment of seizures or
epilepsy, but are not on Medi-Cal managed care plan formularies, or
are subject to prior authorization requirements.  
Medi-Cal beneficiary shall have prompt access to medically necessary
drugs for use in the treatment of seizures and epilepsy that have
been approved   by the federal Food and Drug Administration
for use in the treatment of seizures or epilepsy, including drugs
that are not on the formulary of a Medi-Cal managed care plan or that
are subject to prior authorization. 
   (b) To the extent permitted by federal law, if any drug 
in the seizure or epilepsy therapeutic drug class   used
in the treatment of seizures and epilepsy as  described in
subdivision (a) is prescribed by a Medi-Cal beneficiary's treating
provider, that drug shall be a covered benefit under this chapter.
   (c)  Except as provided in subdivision (d), and
notwithstanding the establishment of a statewide outpatient drug
formulary, a Medi-Cal managed care plan shall provide coverage for a
drug in the seizures and epilepsy therapeutic class, as described in
subdivision (a), regardless of whether the drug is on the plan's
formulary,   (1)     A drug is covered
pursuant to this section  if the treating provider
demonstrates, consistent with federal  law that, 
 law, that  in his or her reasonable, professional judgment,
the drug 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 identified in
Section 1927(g)(1)(B)(i) of the federal Social Security Act (42
U.S.C. Sec.  1396r-8(g)(1)(B)(i)).   1396r-8(g)
(1)(B)(i)), and the drug is not on the formulary for the Medi-Cal
managed care plan.  
   (d) (1) If a Medi-Cal managed care plan elects not to cover a
seizure or epilepsy drug described in subdivision (b), the drug shall
be deemed a noncapitated benefit not reimbursed by the managed care
plan, and shall be available on a fee-for-service basis. The treating
provider shall follow fee-for-service billing instructions for
reimbursement under these circumstances.  
   (2) If a drug is deemed a noncapitated benefit not reimbursed by a
Medi-Cal managed care plan, as described in paragraph (1), the plan'
s contracted rate shall be reduced to reflect the cost of providing
the benefit to the patient on a fee-for-service basis.  

   (2) In a case in which a plan denies coverage for a drug
prescribed under this section, the beneficiary shall be entitled to
an automatic urgent appeal. For purposes of this paragraph,
"automatic urgent appeal" means an appeal in which the plan
immediately notifies the department of the denial of coverage, and
the beneficiary is not required to take any further action. An
automatic urgent appeal shall be resolved within 48 hours after
denial by the plan. The 48-hour period specified in this paragraph
shall be in addition to any time prescribed by federal law.