AB 1814, as amended, Waldron. Prescriber Prevails Act.
Existing law provides for the Medi-Cal program, which is 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 drugsbegin delete whichend deletebegin insert thatend insert 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 that the drug is medically necessary and consistent with federal rules and regulations for labeling and use, as specified.
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 a prescriber’s reasonable, professional judgment
7prevails for the therapeutic drug classes specified in subdivision
8(b) that are not on managed care plan formularies or have prior
9authorization requirements.
10(b) To the extent permitted by federal law, if a drug in any of
11the following therapeutic drug classes is prescribed by a Medi-Cal
12beneficiary’s treating provider, that drug shall be covered under
13the Medi-Cal program:
14(1) Antiretroviral drugs for HIV/AIDS.
15(2) Drugs used to treat hepatitis C.
16(3) Antipsychotics.
17(4) Antirejection drugs.
18(5) Drugs used to treat seizures or epilepsy.
19(c) Except as provided in subdivision (d), and notwithstanding
20the establishment of a statewide outpatient drug formulary, a
21Medi-Cal managed care plan shall cover a drug specified in
22subdivision (b), regardless of whether the drug is on the plan’s
23formulary, if, upon demonstration by the provider that the drug,
24in his or her reasonable, professional judgment, is medically
25necessary and consistent with the federal Food and Drug
26Administration’s labeling and use rules and regulations, as
27supported in at least one of the official compendia, as
defined in
28Section 1927(g)(1)(B)(i) of the federal Social Security Act (42
29U.S.C. Sec. 1396r-8(g)(1)(B)(i)).
30(d) (1) If a Medi-Cal managed care plan chooses not to cover
31begin delete the drugsend deletebegin insert a drugend insert described in subdivision (b), thebegin delete drugsend deletebegin insert drugend insert shall
32be carved out of that plan and covered on a fee-for-service basis.
P3 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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