BILL NUMBER: AB 73 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY MAY 4, 2015
AMENDED IN ASSEMBLY MARCH 16, 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 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 drug upon demonstration
by the provider if the treating provider demonstrates
that the drug is medically necessary , not on the
Medi-Cal managed care plan formulary, and consistent with
federal rules and regulations for labeling and use, as
specified use, under which circumstances the
beneficiary would be entitled to an automatic urgent appeal, as
defined .
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
Prescriber Prevails 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 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. Medi-Cal
beneficiary shall have prompt access to medically necessary drugs for
use in the treatment of the conditions specified in this section and
that have been approved by the federal Food and Drug Administration
for the treatment of those conditions, including drugs that are not
on the formulary of the Medi-Cal managed care plan or that
are subject to prior authorization.
(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 (1)
A drug is covered pursuant to this section if the treating
provider demonstrates, consistent with federal law by
the provider law, that the drug,
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,
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)).
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, the beneficiary shall be entitled to
an automatic urgent appeal. For purposes of this paragraph,
"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.
(1)
(3) 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)
(4) 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 , and independent review by the
Department of Managed Health Care .
(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.