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 subject, to the extent permitted by federal law, 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
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urgent appeal process, as specified, if the treating provider demonstrates that in his or her reasonable, professional judgment, the drug is medically necessary and consistent with specified federal rules and regulations, and the drug is not on the Medi-Cal managed care plan formulary.
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 provider for
15the treatment of seizures and epilepsy, and coverage for that
16prescribed drug is denied by a Medi-Cal managed care plan in
17which the beneficiary is enrolled, that denial shall be reviewed in
18accordance with this section.
19(c) (1) The denial by a Medi-Cal managed care plan of a drug
20prescribed for the treatment of seizures and epilepsy and approved
21by the federal Food and Drug Administration for the use in the
22treatment of seizures and epilepsy is subject to the
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23appeal process described in paragraph (2), if the treating provider
24demonstrates, consistent with federal law, that in his or her
25reasonable, professional judgment, the drug is medically necessary
26and consistent with the federal Food and Drug Administration’s
27labeling and use rules and regulations, as supported in at least one
28of the official compendia identified in Section 1927(g)(1)(B)(i) of
29the federal Social Security Act (42 U.S.C. Sec.
301396r-8(g)(1)(B)(i)), and the drug is not on the formulary for the
31Medi-Cal managed care plan.
32(2) In a case in which a plan denies coverage for a drug
33prescribed for the treatment of seizures and epilepsy and approved
P3 1by the federal Food and Drug Administration for the use in the
2treatment of seizures and epilepsy, the beneficiary shall be entitled
begin delete automaticend delete urgent appeal. For purposes of this section,
begin delete “automatic urgentend delete appeal” means an appeal in which begin delete the
5plan immediately notifies the department of the denial of coverage,
6and the beneficiary is not required to take any further action.end delete
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urgent appeal shall be resolved within
begin delete 48end delete hours after begin delete denial by the plan. The 48-hourend delete period specified in this paragraph shall
12be in addition to any time prescribed by federal law.