BILL NUMBER: AB 68	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  JUNE 1, 2015
	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, 
 subject,  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,
  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,  if the treating
provider demonstrates that in his or her reasonable, professional
judgment, the drug is medically  necessary,  
necessary and consistent with specified federal rules and
regulations, and the drug is  not on the Medi-Cal managed care
plan  formulary, and consistent with specified federal rules
and regulations, under which circumstances the beneficiary would be
entitled to an automatic urgent appeal, as defined.  
formulary. 
   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 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 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.
  provider for the treatment of seizures and epilepsy,
and coverage for that prescribed drug is denied by a Medi-Cal managed
care plan in which the beneficiary is enrolled, that denial shall be
reviewed in accordance with this section. 
   (c) (1)  A drug is covered pursuant to this section
  The denial by a Medi-Cal managed care plan of a drug
prescribed for the treatment of seizures and epilepsy and approved by
the   federal Food and Drug Administration for the use in
the treatment of seizures and epilepsy is subject to the automatic
urgent appeal process described in paragraph (2),  if the
treating provider demonstrates, consistent with federal 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)), and the drug is not on the formulary for the
Medi-Cal managed care plan.
   (2) In a case in which a plan denies coverage for a drug
prescribed  under this section,   for the
treatment of seizures and epilepsy and approved by the federal Food
and Drug Administration for the use in the treatment of  
seizures and epilepsy,  the beneficiary shall be entitled to an
automatic urgent appeal. For purposes of this paragraph,
  section,  "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.