Amended in Assembly May 12, 2014

Amended in Assembly April 23, 2014

Amended in Assembly April 21, 2014

Amended in Assembly March 28, 2014

California Legislature—2013–14 Regular Session

Assembly Bill No. 1814

Introduced by Assembly Member Waldron

( begin delete Coauthor: end delete begin insert Coauthors: end insert Assembly begin delete Member end delete begin insert Members end insert Ammiano begin insert , Bonilla, Chesbro, Gonzalez, Jones, Mullin, and Nestande end insert )

February 18, 2014

An act to add Section 14133.06 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL’S DIGEST

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 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 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:

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.

(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.

begin delete

(2) Drugs used to treat hepatitis C.

(3)

end delete

begin insert (2) end insert  Antipsychotics.

begin delete

(4)

end delete

begin insert (3) end insert  Antirejection drugs.

begin delete

(5)

end delete

begin insert (4) end insert  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 begin insert consistent with federal law end insert 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)).

(d) (1) If a Medi-Cal managed care plan chooses not to cover
a drug described in subdivision (b), the drug 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.