Amended in Assembly March 16, 2015

California Legislature—2015–16 Regular Session

Assembly Bill No. 73

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 73, as amended, Waldron. begin delete Medi-Cal: benefits: prescription drugs. end delete begin insert Prescriber Prevails Act. end insert

Existing law begin delete provides for end delete begin insert establishes end insert the Medi-Cal program, begin delete which is end delete administered by the State Department of Health Care Services, 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. Existing law specifies the benefits provided pursuant to the program, including the purchase of prescribed drugs that are covered subject to utilization controls. Utilization controls include a requirement that the treatment provider obtain prior authorization for providing medical treatment, as specified.

begin delete

This bill would declare the intent of the Legislature to enact legislation to include specified therapeutic drug classes, as prescribed by a licensed prescriber in his or her reasonable, professional judgment, as a covered Medi-Cal benefit, to the extent permitted by federal law.

end delete begin insert

This bill would, to the extent permitted by federal law, provide that drugs in specified therapeutic drug classes that are prescribed by a Medi-Cal beneficiary’s treating provider are covered Medi-Cal benefits. The bill would require, except as specified, that a Medi-Cal managed care plan cover the drug upon demonstration by the provider that the drug is medically necessary and consistent with federal rules and regulations for labeling and use, as specified.

end insert

Vote: majority. Appropriation: no. Fiscal committee:  begin delete no end delete begin insert yes end insert . State-mandated local program: no.

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

begin insert

begin insert SECTION 1. end insert   

end insert

begin insert This act shall be known, and may be cited as, the
Prescriber Prevails Act. end insert

begin insert

begin insert SEC. 2. end insert   

end insert

begin insert Section 14133.06 is added to the end insert begin insert Welfare and
Institutions Code end insert begin insert , to read: end insert

begin insert

begin insert 14133.06. end insert   

(a) It is the intent of the Legislature in enacting this
section that a prescriber’s reasonable, professional judgment
prevails for the therapeutic drug classes specified in subdivision
(b) that are not on managed care plan formularies or have prior
authorization requirements.

(b) To the extent permitted by federal law, if a drug in any of
the following therapeutic drug classes is prescribed by a Medi-Cal
beneficiary’s treating provider, that drug shall be covered under
the Medi-Cal program:

(1) Antiretroviral drugs for HIV/AIDS.

(2) Antipsychotics.

(3) Antirejection drugs.

(4) Drugs used to treat seizures or epilepsy.

(c) Except as provided in subdivision (d), and notwithstanding
the establishment of a statewide outpatient drug formulary, a
Medi-Cal managed care plan shall cover a drug specified in
subdivision (b), regardless of whether the drug is on the plan’s
formulary, if, upon demonstration consistent with federal law by
the provider that the drug, in his or her reasonable, professional
judgment, 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,
as defined in Section 1927(g)(1)(B)(i) of the federal Social Security
Act (42 U.S.C. Sec. 1396r-8(g)(1)(B)(i)).

(1) Medi-Cal managed care plans shall continue to develop
formularies and may also administer prior authorization programs
for the drugs specified in subdivision (b). Providers prescribing
those drugs may be required to provide the plans with requested
information or clinical documentation to support prior
authorization requests. The plans may continue to provide a
temporary three-day supply of medication when medically
necessary.

(2) Consistent with federal law, if a Medi-Cal managed care
plan is unable to complete a prior authorization due to missing
information or because the prescriber’s reasonable, professional
judgment has not been adequately demonstrated, as required under
this subdivision, the plan shall issue a notice of action to the
provider and the beneficiary. The plan shall include in the notice
of action a description of the information that is required from the
provider or the beneficiary in order for the plan to complete the
authorization, and the beneficiary’s rights regarding appeal and
fair hearing options.

(d) (1)   If a Medi-Cal managed care plan chooses not to cover
the drugs specified in subdivision (b), the drugs shall be carved
out of that plan and covered on a fee-for-service basis.

(2) If a drug is carved out of a Medi-Cal managed care plan as
described in paragraph (1), the plan’s contracted rate shall be
reduced accordingly.

end insert

begin delete

SECTION 1.  

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

14133.06.  

It is the intent of the Legislature to enact legislation
to include specified therapeutic drug classes, as prescribed by a
licensed prescriber in his or her reasonable, professional judgment,
as a covered benefit under this chapter, to the extent permitted by
federal law.

end delete