Bill Text: CA AB1814 | 2013-2014 | Regular Session | Amended

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Bill Title: Prescriber Prevails Act.

Spectrum: Slight Partisan Bill (Democrat 5-3)

Status: (Introduced - Dead) 2014-05-23 - In committee: Set, second hearing. Held under submission. [AB1814 Detail]

Download: California-2013-AB1814-Amended.html

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BILL NUMBER: AB 1814	AMENDED
	BILL TEXT

	AMENDED IN ASSEMBLY  MAY 12, 2014
	AMENDED IN ASSEMBLY  APRIL 23, 2014
	AMENDED IN ASSEMBLY  APRIL 21, 2014
	AMENDED IN ASSEMBLY  MARCH 28, 2014

INTRODUCED BY   Assembly Member Waldron
   (  Coauthor:   Assembly Member 
 Ammiano   Coauthors:   Assembly
Members   Ammiano,   Bonilla,   Chesbro,
  Gonzalez,   Jones,  Mullin,  
and Nestande  )

                        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. 
   (2) Drugs used to treat hepatitis C.  
   (3) 
    (2)  Antipsychotics. 
   (4) 
    (3)  Antirejection drugs. 
   (5) 
    (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)).
   (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.