Today's Law As Amended


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AB-1814 Prescriber Prevails Act.(2013-2014)



As Amends the Law Today


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) 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 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.