BILL ANALYSIS Ó
AB 68
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ASSEMBLY THIRD READING
AB
68 (Waldron)
As Amended June 1, 2015
Majority vote
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|Committee |Votes |Ayes |Noes |
| | | | |
| | | | |
|----------------+------+--------------------+----------------------|
|Health |19-0 |Bonta, Maienschein, | |
| | |Bonilla, Burke, | |
| | |Chávez, Chiu, | |
| | |Gomez, Gonzalez, | |
| | | | |
| | | | |
| | |Roger Hernández, | |
| | |Lackey, Nazarian, | |
| | |Patterson, | |
| | | | |
| | | | |
| | |Ridley-Thomas, | |
| | |Rodriguez, | |
| | |Santiago, | |
| | |Steinorth, | |
| | |Thurmond, Waldron, | |
| | |Wood | |
| | | | |
|----------------+------+--------------------+----------------------|
|Appropriations |17-0 |Gomez, Bigelow, | |
| | |Bonta, Calderon, | |
AB 68
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| | |Chang, Daly, | |
| | |Eggman, Gallagher, | |
| | | | |
| | | | |
| | |Eduardo Garcia, | |
| | |Gordon, Holden, | |
| | |Jones, Quirk, | |
| | |Rendon, Wagner, | |
| | |Weber, Wood | |
| | | | |
| | | | |
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SUMMARY: Establishes that a beneficiary has a right to an urgent
appeal process of a Medi-Cal managed care plan's denial of a drug
used in the treatment of seizures and epilepsy and is a drug
approved by the federal Food and Drug Administration for the
treatment of seizures and epilepsy.
EXISTING LAW:
1)Requires states, under the federal Medicaid law, to have a drug
use review program for covered outpatient prescription drugs, to
ensure drugs are appropriate, medically necessary, and not
likely to result in adverse medical effects. Federal law
requires the program to assess data on drug use against
predetermined standards, consistent with specified factors,
including compendia.
2)Provides a schedule of benefits provided in the Medi-Cal
program, including prescription drug benefits.
3)Authorizes the Department of Health Care Services to establish
utilization controls for any Medi-Cal services as long as the
controls are reasonably related to the purpose of establishing
them. Allows the utilization controls include prior
authorization, pre- and post-service audits, limitations on the
number of services and review pursuant to professional
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standards.
FISCAL EFFECT: According to the Assembly Appropriations
Committee, unknown, likely minor, potential increased
administrative costs for the fee-for-service Medi-Cal, and cost
pressure to managed care, for an additional number of appeals.
COMMENTS: The author argues this bill is a reasonable plan to
stabilize those with life-threatening conditions by ensuring a
timely appeal if there is a denial by a managed care plan. The
author notes those who can afford private insurance plans have
doctors who may have more time to work through the existing
pre-authorization processes to attain a higher tier drug for their
patients, however, those in vulnerable low-income situations are
seeing their doctors most likely in clinics, where doctors are
short on time and do not have the resources to follow-up on
preauthorization appeals. The author concludes this bill levels
the playing field for access to medically necessary drugs for low
income patients with serious, chronic or life threatening
conditions by granting them the right to an urgent appeal.
Medi-Cal is one of the largest drug purchasers in the state. The
program spends about $4 billion on prescription drugs, including
indirect expenditures through payment to managed care plans and
direct expenditures in fee for service and for prescription drugs
that are "carved out" of managed care. Carved out means that the
state pays directly for the drug rather than indirectly through a
capitated or fixed rate payment to a Medi-Cal managed care plan.
Facing significantly rising costs, the federal and state
governments have grappled with various cost control measures.
California, to help manage costs, has established a formulary for
the fee-for service program. The formulary is not binding on
Medi-Cal managed care plans, each of which creates their own
formulary. A variety of utilization tools also are used. These
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include limiting prescriptions to six per month, although many
beneficiaries receive more but only after a prior authorization
has been approved. Frequent and high cost prescription drug users
can be identified and case management interventions can be used if
appropriate to reduce drug costs.
Epilepsy is a chronic disorder, the hallmark of which is
recurrent, unprovoked seizures. Many people with epilepsy have
more than one type of seizure and may have other symptoms of
neurological problems as well. Although the symptoms of a seizure
may affect any part of the body, the electrical events that
produce the symptoms occur in the brain. The location of that
event, how it spreads and how much of the brain is affected, and
how long it lasts all have profound effects. These factors
determine the character of a seizure and its impact on the
individual. Having seizures and epilepsy can affect one's safety,
relationships, work, driving and so much more. How epilepsy is
perceived or how people are treated can become a bigger problem
than the seizures.
Anti-epileptic drugs (AEDs) are the main form of treatment for
people with epilepsy. And up to 70% people with epilepsy could
have their seizures completely controlled with AEDs. There are
around 25 AEDs used to treat seizures, and different AEDs work for
different seizures.
Supporters note, on a prior version of this bill, that epilepsy is
a serious medical condition that produces seizures and one seizure
can have significant consequences, including head injury,
limitations in driving or employment, hospitalization and sudden
unexpected death. They argue that failure to effectively manage
epilepsy and prevent breakthrough seizures results in higher costs
to the Medi-Cal program and society through increased
hospitalizations, relapses and deteriorating conditions which
necessitate additional and expensive care.
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There is no known opposition to this bill.
Analysis Prepared by:
Roger Dunstan / HEALTH / (916) 319-2097 FN:
0000833