AB 73, as amended, Waldron. Prescriber Prevails Act.
Existing law establishes the Medi-Cal program, 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.
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 drugbegin delete upon demonstration by the providerend deletebegin insert if the treating provider demonstratesend insert that the drug is medically necessarybegin insert, not on the Medi-Cal managed care plan formulary,end insert and consistent with federal rules and regulations for labeling andbegin delete use, as specifiedend deletebegin insert use, under which circumstances the beneficiary would be entitled to an automatic urgent appeal, as definedend insert.
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
2Prescriber Prevails 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 abegin delete prescriber’s reasonable, professional judgment begin insert Medi-Cal beneficiary shall have
7prevails for the therapeutic drug classes specified in subdivision
8(b) that are not on managed care plan formularies or have prior
9authorization requirements.end delete
10prompt access to medically necessary drugs for use in the treatment
11of the conditions specified in this section and that have been
12approved by the federal Food and Drug Administration for the
13treatment of those conditions, including drugs that are not on the
14formulary of the Medi-Cal managed care
plan or that are subject
15to prior authorization.end insert
16(b) To the extent permitted by federal law, if a drug in any of
17the following therapeutic drug classes is prescribed by a Medi-Cal
18beneficiary’s treating provider, that drug shall be covered under
19the Medi-Cal program:
20(1) Antiretroviral drugs for HIV/AIDS.
21(2) Antipsychotics.
22(3) Antirejection drugs.
23(4) Drugs used to treat seizures or epilepsy.
24(c) begin deleteExcept as provided in subdivision (d), and notwithstanding begin insert(1)end insertbegin insert end insertbegin insertA drug is covered pursuant
25the establishment of a statewide outpatient drug formulary, a
26Medi-Cal managed care plan shall cover a drug specified in
27subdivision (b), regardless of whether the drug is on the plan’s
28formulary, if, upon demonstration end delete
29to this section if the treating provider demonstrates, end insertconsistent
30with federalbegin delete law by the providerend deletebegin insert law,end insert thatbegin delete the drug,end delete in his or her
31
reasonable, professional judgment,begin insert the drugend insert is medically necessary
32and consistent with the federal Food and Drug Administration’s
33labeling and use rules and regulations, as supported in at least one
P3 1of the official compendia, as defined in Section 1927(g)(1)(B)(i)
2of the federal Social Security Act (42 U.S.C. Sec.
3begin delete 1396r-8(g)(1)(B)(i)).end deletebegin insert 1396r-8(g)(1)(B)(i)), and the drug is not on
4the formulary for the Medi-Cal managed care plan.end insert
5(2) In a case in which a plan denies coverage for a drug
6prescribed under this
section, the beneficiary shall be entitled to
7an automatic urgent appeal. For purposes of this paragraph,
8“automatic urgent appeal” means an appeal in which the plan
9immediately notifies the department of the denial of coverage, and
10the beneficiary is not required to take any further action. An
11automatic urgent appeal shall be resolved within 48 hours after
12denial by the plan. The 48-hour period specified in this paragraph
13shall be in addition to any time prescribed by federal law.
14(1)
end delete
15begin insert(3)end insert Medi-Cal managed care plans shall continue to develop
16formularies and may also administer prior authorization
programs
17for the drugs specified in subdivision (b). Providers prescribing
18those drugs may be required to provide the plans with requested
19information or clinical documentation to support prior authorization
20requests. The plans may continue to provide a temporary three-day
21supply of medication when medically necessary.
22(2)
end delete
23begin insert(4)end insert Consistent with federal law, if a Medi-Cal managed care
24plan is unable to complete a prior authorization due to missing
25information or because the prescriber’s reasonable, professional
26judgment has not been adequately demonstrated, as required
under
27this subdivision, the plan shall issue a notice of action to the
28provider and the beneficiary. The plan shall include in the notice
29of action a description of the information that is required from the
30provider or the beneficiary in order for the plan to complete the
31authorization, and the beneficiary’s rights regarding appeal and
32fair hearing optionsbegin insert, and independent review by the end insertbegin insertDepartment
33of Managed Health Careend insert.
34(d) (1) If a Medi-Cal managed care plan chooses not to cover
35the drugs specified in subdivision (b), the drugs shall be carved
36out of that plan and covered on a fee-for-service basis.
P4 1(2) If a drug is carved out of a Medi-Cal managed care plan as
2described in paragraph (1), the plan’s contracted rate shall be
3reduced accordingly.
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