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AB-3285 Medi-Cal: antipsychotic drugs.(2019-2020)

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Date Published: 02/21/2020 09:00 PM
AB3285:v99#DOCUMENT


CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Assembly Bill
No. 3285


Introduced by Assembly Member Irwin

February 21, 2020


An act to amend Sections 14133.1 and 14133.22 of, and to add Section 14133.24 to, the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 3285, as introduced, Irwin. Medi-Cal: antipsychotic drugs.
Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to qualified low-income persons pursuant to a schedule of benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides for the provision of prescription drugs as a Medi-Cal benefit, subject to the list of contract drugs and utilization controls. Existing law limits prescribed drugs under the Medi-Cal program to 6 drugs per month, unless prior authorization is obtained, and except under specified circumstances.
This bill would prohibit requiring prior authorization for an antipsychotic drug to treat the serious mental illness of a Medi-Cal enrollee for 365 days after the initial prescription has been dispensed, and would require automatic approval of an antipsychotic drug to treat the serious mental illness of a Medi-Cal enrollee if the department verifies a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription. The bill would exclude an antipsychotic drug to treat serious mental illness from the Medi-Cal program’s limit of 6 drugs per month. The bill would require the department to allow a pharmacist to dispense a 90-day supply or early refill of a prescribed antipsychotic drug if specified criteria are met.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

The people of the State of California do enact as follows:


SECTION 1.

 Section 14133.1 of the Welfare and Institutions Code is amended to read:

14133.1.
 (a) The director shall determine which of the utilization controls in Section 14133 shall be applied to any a specific service or group of services which that are subject to utilization controls. Each utilization control shall be reasonably related to the purpose for which it is imposed.
(b) Except as provided in Sections 14103.6 and 14133.15, neither prior authorization nor the limitation specified in subdivision (d) of Section 14133 shall be required for the first two services per month which that are included among the services listed in subdivision (a) of Section 14132, or for the first two drug prescriptions purchased during any one month, provided that the prescription drugs are included in the Medi-Cal Drug Formulary and the prescription otherwise conforms to applicable formulary requirements.
(c) The director shall, after a determination of cost benefit, modify or eliminate the requirement of prior authorization as a control for treatment, supplies, or equipment which that costs less than one hundred dollars ($100), except for prescribed drugs, other than those prescribed drugs specified in subdivision (d), provided that the requirement of prior authorization for treatment, supplies, or equipment may be reinstituted upon a finding by the department that the elimination of the requirement has resulted in unnecessary utilization, and upon notice to the Joint Legislative Budget Committee 30 days prior to before the reinstitution of the requirement of prior authorization. Modification of the utilization controls may include establishing prior authorization review thresholds at levels other than one hundred dollars ($100) if indicated by the cost-benefit analysis.
(d) (1) Prior authorization shall not be required for an antipsychotic drug for the treatment of a serious mental illness, as defined in subdivision (e) of Section 5452, for a period of 365 days after the initial prescription has been dispensed.
(2) A prescription for an antipsychotic drug for the treatment of a serious mental illness, as defined in subdivision (e) of Section 5452, shall automatically be approved if the department verifies a record of a paid claim that documents a diagnosis of a serious mental illness within 365 days before the date of that prescription.

SEC. 2.

 Section 14133.22 of the Welfare and Institutions Code is amended to read:

14133.22.
 (a) Prescribed drugs shall be limited to no more than six per month, unless prior authorization is obtained.
(b) The limit in subdivision (a) shall not apply to patients receiving care in a nursing facility.
(c) The limit in subdivision (a) shall not apply to drugs for family planning.
(d) The limit in subdivision (a) shall not apply if any of the prescribed drugs are antipsychotic medications for the treatment of a serious mental illness, as defined in subdivision (e) of Section 5452.

(d)

(e) The department may issue Medi-Cal cards that contain labels for prescribed drugs to implement this section.

(e)

(f) In carrying out this section, the department may contract either directly, or through the fiscal intermediary, for pharmacy consultant staff necessary to accomplish the treatment authorization request reviews.

SEC. 3.

 Section 14133.24 is added to the Welfare and Institutions Code, to read:

14133.24.
 (a) The department shall allow a pharmacist to dispense a 90-day supply of a prescribed antipsychotic drug for the treatment of a serious mental illness, as defined in subdivision (e) of Section 5452 if the prescription otherwise conforms to applicable formulary requirements and all of the following:
(1) The prescriber approves a 90-day supply.
(2) The patient is over 18 years of age.
(3) All required utilization controls have been met.
(4) The patient has filled at least a 30-day supply for the same prescription in the previous 90 days.
(b) The department shall allow a pharmacist to dispense an early refill of a prescribed antipsychotic if the drug is included on the Medi-Cal Drug Formulary, and the prescription otherwise conforms to applicable formulary requirements and all of the following:
(1) For a 30-day supply, the dispensing takes place at least 23 days after, but not more than 30 days after, either of the following:
(A) The original date that the prescription was distributed to the beneficiary.
(B) The date of the most recent refill was distributed to the beneficiary.
(2) The number of early refills shall not exceed three in a calendar year.