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
begin delete require,end delete to the extent permitted by federal law, begin delete 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,end delete if the treating provider demonstrates that in his or her reasonable, professional judgment, the drug is medically begin delete necessary,end delete not on the Medi-Cal managed care plan begin delete formulary, and consistent with specified federal rules and regulations, under which circumstances the beneficiary would be entitled to an automatic urgent appeal, as defined.end delete
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
This act shall be known, and may be cited, as the
2Patient Access to Prescribed Epilepsy Treatments Act.
Section 14133.06 is added to the Welfare and
4Institutions Code, to read:
(a) It is the intent of the Legislature in enacting this
6section that a Medi-Cal beneficiary shall have prompt access to
7medically necessary drugs for use in the treatment of seizures and
8epilepsy that have been approved by the federal Food and Drug
9Administration for use in the treatment of seizures or epilepsy,
10including drugs that are not on the formulary of a Medi-Cal
11managed care plan or that are subject to prior authorization.
12(b) To the extent permitted by federal law, if any drug used in
13the treatment of seizures and epilepsy as described in subdivision
14(a) is prescribed by a Medi-Cal beneficiary’s treating
begin delete provider,
15that drug shall be a covered benefit under this chapter.end delete
begin deleteA drug is covered pursuant to this section end deleteif
the treating provider
26demonstrates, consistent with federal law, that in his or her
27reasonable, professional judgment, the drug is medically necessary
28and consistent with the federal Food and Drug Administration’s
P3 1labeling and use rules and regulations, as supported in at least one
2of the official compendia identified in Section 1927(g)(1)(B)(i) of
3the federal Social Security Act (42 U.S.C. Sec.
41396r-8(g)(1)(B)(i)), and the drug is not on the formulary for the
5Medi-Cal managed care plan.
6(2) In a case in which a plan denies coverage for a drug
begin delete under this section,end delete
10 the beneficiary shall be entitled to an automatic urgent appeal. For
11purposes of this
begin delete paragraph,end delete “automatic urgent appeal”
12means an appeal in which the plan immediately notifies the
13department of the denial of coverage, and the beneficiary is not
14required to take any further action. An automatic urgent appeal
15shall be resolved within 48 hours after denial by the plan. The
1648-hour period specified in this paragraph shall be in addition to
17any time prescribed by federal law.