Amended in Assembly June 1, 2015

Amended in Assembly April 30, 2015

Amended in Assembly March 26, 2015

California Legislature—2015–16 Regular Session

Assembly BillNo. 68


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, wouldbegin delete require,end deletebegin insert subject,end insert 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 deletebegin insert the denial of coverage by a Medi-Cal managed care plan of any drug in the seizure or epilepsy therapeutic drug class prescribed by a Medi-Cal beneficiary’s treating provider to an automatic urgent appeal process, as specified,end insert if the treating provider demonstrates that in his or her reasonable, professional judgment, the drug is medicallybegin delete necessary,end deletebegin insert necessary and consistent with specified federal rules and regulations, and the drug isend insert not on the Medi-Cal managed care planbegin 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 deletebegin insert formulary.end insert

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.

The people of the State of California do enact as follows:

P2    1

SECTION 1.  

This act shall be known, and may be cited, as the
2Patient Access to Prescribed Epilepsy Treatments Act.

3

SEC. 2.  

Section 14133.06 is added to the Welfare and
4Institutions Code
, to read:

5

14133.06.  

(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 treatingbegin delete provider,
15that drug shall be a covered benefit under this chapter.end delete
begin insert provider
16for the treatment of seizures and epilepsy, and coverage for that
17prescribed drug is denied by a Medi-Cal managed care plan in
18which the beneficiary is enrolled, that denial shall be reviewed in
19accordance with this section.end insert

20(c) (1) begin deleteA drug is covered pursuant to this section end deletebegin insertThe denial by
21a Medi-Cal managed care plan of a drug prescribed for the
22treatment of seizures and epilepsy and approved by the end insert
begin insertfederal
23Food and Drug Administration for the use in the treatment of
24seizures and epilepsy is subject to the automatic urgent appeal
25process described in paragraph (2), end insert
if 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
7prescribedbegin delete under this section,end deletebegin insert for the treatment of seizures and
8epilepsy and approved by the federal Food and Drug
9Administration for the use in the treatment of seizures and epilepsy,end insert

10 the beneficiary shall be entitled to an automatic urgent appeal. For
11purposes of thisbegin delete paragraph,end deletebegin insert section,end insert “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.



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