BILL NUMBER: AB 339 AMENDED
BILL TEXT
AMENDED IN SENATE SEPTEMBER 1, 2015
AMENDED IN SENATE JULY 16, 2015
AMENDED IN SENATE JULY 7, 2015
AMENDED IN SENATE JUNE 24, 2015
AMENDED IN ASSEMBLY JUNE 1, 2015
AMENDED IN ASSEMBLY MAY 20, 2015
AMENDED IN ASSEMBLY MAY 4, 2015
AMENDED IN ASSEMBLY APRIL 7, 2015
INTRODUCED BY Assembly Member Gordon
(Coauthor: Assembly Member Atkins)
FEBRUARY 13, 2015
An act to amend Sections 1367.24 and
Section 1367.205 of, to add Sections 1367.41 and 1367.42 to,
and to add and repeal Section 1342.71 to, of,
the Health and Safety Code, and to amend Section 10123.192 of,
to add Section 10123.201 to, and to add and repeal Section 10123.193
to, of, the Insurance Code, relating to
health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
AB 339, as amended, Gordon. Health care coverage: outpatient
prescription drugs.
(1) Existing law, the Knox-Keene Health Care Service Plan Act of
1975, provides for the licensure and regulation of health care
service plans by the Department of Managed Health Care and makes a
willful violation of the act a crime. Existing law also provides for
the regulation of health insurers by the Department of Insurance.
Existing law requires a health care service plan or insurer that
provides prescription drug benefits and maintains one or more drug
formularies to make specified information regarding the formularies
available to the public and other specified entities. Existing law
also specifies requirements for those plans and insurers regarding
coverage and cost sharing of specified prescription drugs.
This bill would prohibit the formulary or formularies for
outpatient prescription drugs maintained by a health care service
plan or health insurer from discouraging the enrollment of
individuals with health conditions and from reducing the generosity
of the benefit for enrollees or insureds with a particular condition.
The bill, until January 1, 2021, 2020,
would provide that the copayment, coinsurance, or any other form of
cost sharing for a covered outpatient prescription drug for an
individual prescription shall not exceed $250 for a supply of up to
30 days, except as specified. specified, and
would prohibit, for a nongrandfathered individual or small group plan
contract or policy, the deductible for outpatient drugs from
exceeding a specified amount. The bill would make these
cost-sharing limits applicable only to covered outpatient
prescription drugs that constitute essential health benefits, as
defined. The bill would require a plan contract or policy to cover a
single-tablet prescription drug regimen for combination
antiretroviral drug treatments that are medically necessary for the
treatment of AIDS/HIV, as specified. The bill would
prohibit, except as specified, a plan contract or policy from placing
more than 50% of drugs approved by the United States Food and Drug
Administration that are in the same drug class into the 2 highest
cost tiers of a drug formulary. The bill
bill, until January 1, 2020, would require a plan
contract or policy to use specified definitions for each tier of a
drug formulary. The bill would make related findings and
declarations.
This bill would require a health care service plan contract
or health insurer insurance policy
that provides coverage for outpatient prescription drugs to
provide coverage for medically necessary prescription drugs,
including those for which there is not a therapeutic
equivalent, nonformulary drugs determined to be
medically necessary, and, for an insurer, would
require copayments, coinsurance, and other cost sharing for
outpatient prescription drugs to be reasonable.
This bill would make these provisions applicable to
nongrandfathered group health care service plan contracts or
health insurance policies that are offered, renewed, or amended on
or after July 1, 2016, and applicable to nongrandfathered individual
health care service plan contracts or health insurance
policies that are offered, renewed, or amended on or after January 1,
2017.
(2) Existing law requires every health care service plan that
provides prescription drug benefits to maintain an
expeditious process by which prescribing providers may obtain
authorization for a medically necessary nonformulary prescription
drug, and requires these plans to maintain specified
information that is required to be made available to the Director of
the Department of Managed Health Care upon request.
This bill would also impose these requirements on a health insurer
that provides prescription drug benefits, as provided. The
bill would require a plan or insurer to respond to authorization
requests for nonformulary prescription drugs within specified
timeframes. The bill would authorize an insurer to require
step therapy, as defined, when more than one drug is appropriate for
the treatment of a medical condition, subject to specified
requirements. The bill would require an insurer that requires step
therapy to have an expeditious process in place to authorize
exceptions to step therapy when medically necessary and to conform
effectively and efficiently with continuity of care requirements. The
bill, with regard to an insured changing policies, would prohibit a
new insurer from requiring the insured to repeat step therapy when
that person is already being treated for a medical condition by a
prescription drug, as specified. The For plan
years commencing on or after January 1, 2017, the bill, except
as specified, would require a plan or insurer that provides
essential health benefits to allow an enrollee or insured to access
his or her prescription drug benefits at an in-network retail
pharmacy, and would authorize a plan or insurer to charge an enrollee
or insured a different cost sharing for obtaining a covered drug at
a retail pharmacy, and would require that cost-sharing amount to
count towards the plan's or insurer's annual out-of-pocket
limitation, as specified.
This bill, commencing January 1, 2017, would require a plan or
insurer to maintain a pharmacy and therapeutics committee that is
responsible for developing, maintaining, and overseeing any drug
formulary list, as provided. The bill would require the committee to,
among other things, evaluate and analyze treatment protocols and
procedures related to the plan's or insurer's drug formulary at least
annually.
(3) Existing law requires the Department of Managed Health Care
and the Department of Insurance to jointly develop a standard
formulary template by January 1, 2017, and requires plans and
insurers to use that template to display formularies, as specified.
Existing law requires the standard formulary template to include
specified information.
This bill would require the standard formulary template to include
additional specified information, including which medications are
covered, including both generic and brand name.
(4) Because a willful violation of the bill's requirements
relative to health care service plans would be a crime, this bill
would impose a state-mandated local program.
The California Constitution requires the state to reimburse local
agencies and school districts for certain costs mandated by the
state. Statutory provisions establish procedures for making that
reimbursement.
This bill would provide that no reimbursement is required by this
act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. Section 1342.71 is added to the Health and Safety Code,
to read:
1342.71. (a) The Legislature hereby finds and declares all of the
following:
(1) The federal Patient Protection and Affordable Care Act, its
implementing regulations and guidance, and related state law prohibit
discrimination based on a person's expected length of life, present
or predicted disability, degree of medical dependency, quality of
life, or other health conditions, including benefit designs that have
the effect of discouraging the enrollment of individuals with
significant health needs.
(2) The Legislature intends to build on existing state and federal
law to ensure that health coverage benefit designs do not have an
unreasonable discriminatory impact on chronically ill individuals,
and to ensure affordability of outpatient prescription drugs.
(3) Assignment of all or most prescription medications that treat
a specific medical condition to the highest cost tiers of a formulary
may effectively discourage enrollment by chronically ill
individuals, and may result in lower adherence to a prescription drug
treatment regimen.
(b) A nongrandfathered group health care service plan
contract that is offered, amended, or renewed on or after July 1,
2016, shall comply with this section. A nongrandfathered individual
health care service plan contract that is offered, amended,
or renewed on or after January 1, 2017, shall comply with this
section. The cost-sharing limits established by this section apply
only to outpatient prescription drugs covered by the contract that
constitute essential health benefits, as defined in Section 1367.005.
This section does not apply to Medi-Cal managed care
contracts.
(c) (1) A health care service plan contract that provides coverage
for outpatient prescription drugs shall cover medically necessary
prescription drugs, including nonformulary drugs determined to be
medically necessary consistent with this chapter.
(2) If a nonformulary drug is authorized consistent with this
chapter, the cost sharing shall be the same as for a formulary drug.
(c) Consistent
(d) (1)
Consistent with federal law and guidance, and
notwithstanding Section 1342.7 and any regulations adopted pursuant
to that section, guidance, the formulary or
formularies for outpatient prescription drugs maintained by the
health care service plan shall not discourage the enrollment of
individuals with health conditions and shall not reduce the
generosity of the benefit for enrollees with a particular
condition. condition in a manner that is not based on
a clinical indication or reasonable medical management practices.
Section 1342.7 and any regulations adopted pursuant to that section
shall be interpreted in a manner that is consistent with this
section.
(1)
( 2) For combination antiretroviral drug
treatments that are medically necessary for the treatment of
AIDS/HIV, a health care service plan contract shall cover a
single-tablet drug regimen that is as effective as a multitablet
regimen unless, consistent with clinical guidelines and peer-reviewed
scientific and medical literature, the multitablet regimen is
clinically equally or more effective and more likely to result in
adherence to a drug regimen.
(2) No more than 50 percent of drugs approved by the United States
Food and Drug Administration (FDA) that are in the same drug class
may be assigned to the two highest cost tiers of a drug formulary.
All health care service plan formularies shall include at least one
drug in the lower cost tiers if all FDA-approved drugs in the same
drug class would otherwise qualify for the highest cost tiers and at
least three drugs in that class are available as FDA-approved drugs.
The drug or drugs assigned to the lower cost tiers pursuant to this
paragraph shall be the drug or drugs that were most often prescribed
during the immediately preceding plan year, based on the health care
service plan's experience.
(d)
( e) (1) With respect to an individual or
group health care service plan contract subject to Section 1367.006,
the copayment, coinsurance, or any other form of cost sharing for a
covered outpatient prescription drug for an individual prescription
for a supply of up to 30 days shall not exceed two hundred fifty
dollars ($250), except as provided in paragraphs (2) and (3).
(2) With respect to products with actuarial value at, or
equivalent to, the bronze level, cost sharing for a covered
outpatient prescription drug for an individual prescription for a
supply of up to 30 days shall not exceed five hundred dollars
($500). ($500), except as provided in
paragraph (3).
(3) For a health care service plan contract that is a "high
deductible health plan" under the definition set forth in Section 223
(c)(2) of Title 26 of the United States Code, paragraph
paragraphs (1) and (2) of this
subdivision shall apply only once an enrollee's deductible has been
satisfied for the year.
(4) For a nongrandfathered individual or small group health care
service plan contract, the deductible for outpatient drugs, if any,
shall not exceed twice the amount specified in paragraph (1) or (2),
respectively.
(5) For purposes of paragraphs (1) and (2), "any other form of
cost sharing" shall not include deductible.
(e)
( f) (1) If a health care service plan
contract maintains a drug formulary grouped into tiers that includes
a fourth tier or specialty tier, a health care
service plan contract shall use the following definitions for each
tier of the drug formulary:
(A) Tier one shall consist of most generic drugs and low
cost low-cost preferred brand name
drugs.
(B) Tier two shall consist of nonpreferred generic drugs,
preferred brand name drugs, and any other drugs recommended by the
health care service plan's pharmacy and therapeutics committee based
on safety and efficacy and not solely based on the cost of
the prescription drug, and which generally have a preferred and often
less costly therapeutic alternative at a lower tier.
safety, efficacy, and cost.
(C) Tier three shall consist of nonpreferred brand name drugs
or drugs that are recommended by the health care service plan'
s pharmacy and therapeutics committee based on safety and
efficacy and not solely based on the cost of the prescription drug.
safety, efficacy, and cost, or that generally have a
preferred and often less costly therapeutic alternative at a lower
tier.
(D) Tier four shall consist of drugs that are biologics, drugs
that the FDA or the manufacturer requires to be distributed through a
specialty pharmacy, drugs that require the enrollee to have special
training or clinical monitoring for self-administration, or drugs
that cost the health plan more than six hundred dollars ($600) net of
rebates. rebates for a one-month supply.
(2) This section does not require a health care service
plan contract to include a fourth tier. A health care
service plan contract may maintain a drug formulary with fewer than
four tiers.
(3) This section shall not be construed to limit a health care
service plan from placing any drug in a lower tier.
(f)
( g) A health care service plan contract
shall ensure that the placement of prescription drugs on formulary
tiers is based on clinically indicated, reasonable medical management
practices.
(g)
( h) This section shall not be construed to
require a health care service plan to impose cost sharing. This
section shall not be construed to require cost sharing for
prescription drugs that state or federal law otherwise requires to be
provided without cost sharing.
(h)
( i) This section does not require or
authorize a health care service plan that contracts with the State
Department of Health Care Services to provide services to Medi-Cal
beneficiaries to provide coverage for prescription drugs that are not
required pursuant to those programs or contracts, or to limit or
exclude any prescription drugs that are required by those programs or
contracts.
(j) In the provision of outpatient prescription drug coverage, a
health care service plan may utilize formulary, prior authorization,
step therapy, or other reasonable medical management practices
consistent with this chapter.
(k) This section shall not apply to a health care service plan
that contracts with the State Department of Health Care Services.
(i)
( l) This section shall remain in effect
only until January 1, 2021, 2020, and as
of that date is repealed, unless a later enacted statute, that is
enacted before January 1, 2021, 2020,
deletes or extends that date.
SEC. 2. Section 1342.71 is added to the Health and Safety Code, to
read:
1342.71. (a) The Legislature hereby finds and declares all of the
following:
(1) The federal Patient Protection and Affordable Care Act, its
implementing regulations and guidance, and related state law prohibit
discrimination based on a person's expected length of life, present
or predicted disability, degree of medical dependency, quality of
life, or other health conditions, including benefit designs that have
the effect of discouraging the enrollment of individuals with
significant health needs.
(2) The Legislature intends to build on existing state and federal
law to ensure that health coverage benefit designs do not have an
unreasonable discriminatory impact on chronically ill individuals,
and to ensure affordability of outpatient prescription drugs.
(3) Assignment of all or most prescription medications that treat
a specific medical condition to the highest cost tiers of a formulary
may effectively discourage enrollment by chronically ill
individuals, and may result in lower adherence to a prescription drug
treatment regimen.
(b) A nongrandfathered group health care service plan
contract that is offered, amended, or renewed on or after July 1,
2016, shall comply with this section. A nongrandfathered individual
health care service plan contract that is offered, amended,
or renewed on or after January 1, 2017, shall comply with this
section. The cost-sharing limits established by this section
apply only to outpatient prescription drugs covered by the contract
that constitute essential health benefits, as defined in Section
1367.005. This section does not apply to Medi-Cal managed care
contracts.
(c) (1) A health care service plan contract that provides coverage
for outpatient prescription drugs shall cover medically necessary
prescription drugs, including nonformulary drugs determined to be
medically necessary consistent with this chapter.
(2) If a nonformulary drug is authorized consistent with this
chapter, the cost sharing shall be the same as for a formulary drug.
(c)
( d) (1) Consistent
with federal law and guidance, and notwithstanding Section
1342.7 and any regulations adopted pursuant to that section,
guidance, the formulary or formularies for
outpatient prescription drugs maintained by the health care service
plan shall not discourage the enrollment of individuals with health
conditions and shall not reduce the generosity of the benefit for
enrollees with a particular condition.
condition in a manner that is not based on a clinical indication
or reasonable medical management practices. Section 1342.7 and any
regulations adopted pursuant to that section shall be interpreted in
a manner that is consistent with this section.
(1)
( 2) For combination antiretroviral drug
treatments that are medically necessary for the treatment of
AIDS/HIV, a health care service plan contract shall cover a
single-tablet drug regimen that is as effective as a multitablet
regimen unless, consistent with clinical guidelines and peer-reviewed
scientific and medical literature, the multitablet regimen is
clinically equally or more effective and more likely to result in
adherence to a drug regimen.
(2) No more than 50 percent of drugs approved by the United States
Food and Drug Administration (FDA) that are in the same drug class
may be assigned to the two highest cost tiers of a drug formulary.
All health care service plan formularies shall include at least one
drug in the lower cost tiers if all FDA-approved drugs in the same
drug class would otherwise qualify for the highest cost tiers and at
least three drugs in that class are available as FDA-approved drugs.
The drug or drugs assigned to the lower cost tiers pursuant to this
paragraph shall be the drug or drugs that were most often prescribed
during the immediately preceding plan year, based on the health care
service plan's experience.
(d) (1) If a health care service plan contract maintains a drug
formulary grouped into tiers that includes a fourth tier or specialty
tier, a health care service plan contract shall use the following
definitions for each tier of the drug formulary:
(A) Tier one shall consist of most generic drugs and low cost
preferred brand drugs.
(B) Tier two shall consist of nonpreferred generic drugs,
preferred brand name drugs, and any other drugs recommended by the
health care service plan's pharmacy and therapeutics committee based
on safety and efficacy and not solely based on the cost of the
prescription drug, and which generally have a preferred and often
less costly therapeutic alternative at a lower tier.
(C) Tier three shall consist of nonpreferred brand name drugs that
are recommended by the health care service plan's pharmacy and
therapeutics committee based on safety and efficacy and not solely
based on the cost of the prescription drug.
(D) Tier four shall consist of drugs that are biologics, drugs
that the FDA or the manufacturer requires to be distributed through a
specialty pharmacy, drugs that require the enrollee to have special
training or clinical monitoring for self-administration, or drugs
that cost the health plan more than six hundred dollars ($600) net of
rebates.
(2) This section does not require a health care service plan
contract to include a fourth tier. A
(e) (1) A
health care service plan contract may maintain a drug formulary with
fewer than four tiers.
(2) This section shall not be construed to limit a health care
service plan from placing any drug in a lower tier.
(e)
( f) A health care service plan contract
shall ensure that the placement of prescription drugs on formulary
tiers is based on clinically indicated, reasonable medical management
practices.
(f)
( g) This section shall not be construed to
require a health care service plan to impose cost sharing. This
section shall not be construed to require cost sharing for
prescription drugs that state or federal law otherwise requires to be
provided without cost sharing.
(g)
( h) This section does not require or
authorize a health care service plan that contracts with the State
Department of Health Care Services to provide services to Medi-Cal
beneficiaries to provide coverage for prescription drugs that are not
required pursuant to those programs or contracts, or to limit or
exclude any prescription drugs that are required by those programs or
contracts.
(i) In the provision of outpatient prescription drug coverage, a
health care service plan may utilize formulary, prior authorization,
step therapy, or other reasonable medical management practices
consistent with this chapter.
(j) This section shall not apply to a health care service plan
that contracts with the State Department of Health Care Services.
(h)
( k) This section shall become operative on
January 1, 2021. 2020.
SEC. 3. Section 1367.24 of the Health and
Safety Code is amended to read:
1367.24. (a) (1) Every health care service plan that provides
prescription drug benefits shall maintain an expeditious process by
which prescribing providers may obtain authorization for a medically
necessary nonformulary prescription drug. On or before July 1, 1999,
every health care service plan that provides prescription drug
benefits shall file with the department a description of its process
for responding to authorization requests for nonformulary drugs. Any
changes to this process shall be filed with the department pursuant
to Section 1352. The plan shall provide that the enrollee, the
enrollee's designee, or the enrollee's prescribing provider may seek
an authorization for a nonformulary prescription drug.
(2) Each plan shall respond to an authorization request within 72
hours following receipt of the authorization request for a nonurgent
authorization. If the plan grants the authorization request, the plan
shall provide coverage of the nonformulary drug for the duration of
the prescription, including refills.
(3) Each plan shall provide that an urgent authorization may be
obtained within 24 hours if an enrollee is suffering from a health
condition that may seriously jeopardize the enrollee's life, health,
or ability to regain maximum function, or if an enrollee is
undergoing a current course of treatment using a nonformulary
prescription drug. A plan that grants an exception based on these
urgent circumstances shall provide coverage of the nonformulary
prescription drug for the duration of that urgent condition.
(4) Each plan shall provide a written description of its most
current process to its prescribing providers. For purposes of this
section, a prescribing provider shall include a provider authorized
to write a prescription, pursuant to subdivision (a) of Section 4040
of the Business and Professions Code, to treat a medical condition of
an enrollee.
(b) Any plan that disapproves a request made pursuant to
subdivision (a) by a prescribing provider to obtain authorization for
a nonformulary drug shall provide the reasons for the disapproval in
a notice provided to the enrollee. The notice shall indicate that
the enrollee may file a grievance with the plan if the enrollee
objects to the disapproval, including any alternative drug or
treatment offered by the plan. The notice shall comply with
subdivision (b) of Section 1368.02.
(c) The process described in subdivision (a) by which prescribing
providers may obtain authorization for medically necessary
nonformulary drugs shall not apply to a nonformulary drug that has
been prescribed for an enrollee in conformance with the provisions of
Section 1367.22.
(d) The process described in subdivision (a) by which enrollees
may obtain medically necessary nonformulary drugs, including
specified timelines for responding to prescribing provider
authorization requests, shall be described in evidence of coverage
and disclosure forms, as required by subdivision (a) of Section 1363,
issued on or after July 1, 1999.
(e) Every health care service plan that provides prescription drug
benefits shall maintain, as part of its books and records under
Section 1381, all of the following information, which shall be made
available to the director upon request:
(1) The complete drug formulary or formularies of the plan, if the
plan maintains a formulary, including a list of the prescription
drugs on the formulary of the plan by major therapeutic category with
an indication of whether any drugs are preferred over other drugs.
(2) Records developed by the pharmacy and therapeutic committee of
the plan, or by others responsible for developing, modifying, and
overseeing formularies, including medical groups, individual practice
associations, and contracting pharmaceutical benefit management
companies, used to guide the drugs prescribed for the enrollees of
the plan, that fully describe the reasoning behind formulary
decisions.
(3) Any plan arrangements with prescribing providers, medical
groups, individual practice associations, pharmacists, contracting
pharmaceutical benefit management companies, or other entities that
are associated with activities of the plan to encourage formulary
compliance or otherwise manage prescription drug benefits.
(f) If a plan provides prescription drug benefits, the department
shall, as part of its periodic onsite medical survey of each plan
undertaken pursuant to Section 1380, review the performance of the
plan in providing those benefits, including, but not limited to, a
review of the procedures and information maintained pursuant to this
section, and describe the performance of the plan as part of its
report issued pursuant to Section 1380.
(g) The director shall not publicly disclose any information
reviewed pursuant to this section that is determined by the director
to be confidential pursuant to state law.
(h) For purposes of this section, "authorization" means approval
by the health care service plan to provide payment for the
prescription drug.
(i) (1) Nonformulary prescription drugs shall include any drug for
which an enrollee's copayment or out-of-pocket costs are different
than the copayment for a formulary prescription drug, except as
otherwise provided by law or regulation or in cases in which the drug
has been excluded in the plan contract pursuant to Section 1342.7.
(2) If a nonformulary drug is authorized consistent with this
section, the cost sharing shall be the same as for a formulary drug
consistent with, until January 1, 2021, subdivision (d) of Section
1342.71.
(j) Nothing in this section shall be construed to affect an
enrollee's or subscriber's eligibility to submit a grievance to the
department for review under Section 1368 or to apply to the
department for an independent medical review under Section 1370.4 or
Article 5.55 (commencing with Section 1374.30) of this chapter.
(k) Nothing in this section shall be construed to restrict or
impair the application of any other provision of this chapter,
including, but not limited to, Section 1367, which includes among its
requirements that a health care service plan furnish services in a
manner providing continuity of care and demonstrate that medical
decisions are rendered by qualified medical providers unhindered by
fiscal and administrative management.
SEC. 4. SEC. 3. Section 1367.41 is
added to the Health and Safety Code, immediately following Section
1367.4, to read:
1367.41. (a) Commencing January 1, 2017, a plan
health care service plan shall maintain a
pharmacy and therapeutics committee that shall be responsible for
developing, maintaining, and overseeing any drug formulary list. If
the plan delegates responsibility for the formulary to any entity,
the obligation of the plan to comply with this chapter shall not be
waived.
(b) The pharmacy and therapeutics committee board membership shall
conform with both of the following:
(1) Represent a sufficient number of clinical specialties to
adequately meet the needs of enrollees.
(2) Consist of a majority of individuals who are practicing
physicians, practicing pharmacists, and other practicing health
professionals who are licensed to prescribe drugs.
(c) Members of the board shall abstain from voting on any issue in
which the member has a conflict of interest with respect to the
issuer or a pharmaceutical manufacturer.
(d) At least 20 percent of the board membership shall not have a
conflict of interest with respect to the issuer or any pharmaceutical
manufacturer.
(e) The pharmacy and therapeutics committee shall meet at least
quarterly and shall maintain written documentation of the rationale
for its decisions regarding the development of, or revisions to, the
formulary drug list.
(f) The pharmacy and therapeutics committee shall do all of the
following:
(1) Develop and document procedures to ensure appropriate drug
review and inclusion.
(2) Base clinical decisions on the strength of the scientific
evidence and standards of practice, including assessing peer-reviewed
medical literature, pharmacoeconomic studies, outcomes research
data, and other related information.
(3) Consider the therapeutic advantages of drugs in terms of
safety and efficacy when selecting formulary drugs.
(4) Review policies that guide exceptions and other utilization
management processes, including drug utilization review, quantity
limits, and therapeutic interchange.
(5) Evaluate and analyze treatment protocols and procedures
related to the plan's formulary at least annually.
(6) Review and approve all clinical prior authorization criteria,
step therapy protocols, and quantity limit restrictions applied to
each covered drug.
(7) Review new United States Food and Drug Administration-approved
drugs and new uses for existing drugs.
(8) Ensure that the plan's formulary drug list or lists cover a
range of drugs across a broad distribution of therapeutic
categories and classes and
recommended drug treatment regimens that treat all disease states and
do not discourage enrollment by any group of enrollees.
(9) Ensure that the plan's formulary drug list or lists provide
appropriate access to drugs that are included in broadly accepted
treatment guidelines and that are indicative of general best
practices at the time.
(g) This section shall be interpreted consistent with federal
guidance issued under paragraph (3) of subdivision (a) of Section
156.122 of Title 45 of the Code of Federal Regulations. This section
shall apply to the individual, small group, and large group markets.
SEC. 5. SEC. 4. Section 1367.42 is
added to the Health and Safety Code, to read:
1367.42. (a) A For plan years commencing
on or after January 1, 2017, a plan that provides essential
health benefits shall allow an enrollee to access prescription drug
benefits at an in-network retail pharmacy unless the prescription
drug is subject to restricted distribution by the United States Food
and Drug Administration or requires special handling, provider
coordination, or patient education that cannot be provided by a
retail pharmacy.
(b) A nongrandfathered individual or small group health plan
contract may charge an enrollee a different cost sharing for
obtaining a covered drug at a retail pharmacy, but all cost sharing
shall count toward the plan's annual limitation on cost sharing
consistent with Section 1367.006.
SEC. 6. SEC. 5. Section 1367.205 of
the Health and Safety Code is amended to read:
1367.205. (a) In addition to the list required to be provided
under Section 1367.20, a health care service plan that provides
prescription drug benefits and maintains one or more drug formularies
shall do all of the following:
(1) Post the formulary or formularies for each product offered by
the plan on the plan's Internet Web site in a manner that is
accessible and searchable by potential enrollees, enrollees,
providers, the general public, the department, and federal agencies
as required by federal law or regulations.
(2) Update the formularies posted pursuant to paragraph (1) with
any change to those formularies on a monthly basis.
(3) No later than six months after the date that a standard
formulary template is developed under subdivision (b), use that
template to display the formulary or formularies for each product
offered by the plan.
(b) (1) By January 1, 2017, the department and the Department of
Insurance shall jointly, and with input from interested parties from
at least one public meeting, develop a standard formulary template
for purposes of paragraph (3) of subdivision (a). In developing the
template, the department and Department of Insurance shall take into
consideration existing requirements for reporting of formulary
information established by the federal Centers for Medicare and
Medicaid Services. To the extent feasible, in developing the
template, the department and the Department of Insurance shall
evaluate a way to include on the template, in addition to the
information required to be included under paragraph (2), cost-sharing
information for drugs subject to coinsurance.
(2) The standard formulary template shall include the notification
described in subdivision (c) of Section 1363.01, and as applied to a
particular formulary for a product offered by a plan, shall do all
of the following:
(A) Include information on cost sharing
cost-sharing tiers and utilization controls, including prior
authorization or step therapy requirements, for each drug covered by
the product.
(B) Indicate any drugs on the formulary that are preferred over
other drugs on the formulary.
(C) Include information to educate enrollees about the differences
between drugs administered or provided under a health care service
plan's medical benefit and drugs prescribed under a health care
service plan's prescription drug benefit and about how to obtain
coverage information regarding drugs that are not covered under the
plan's prescription drug benefit.
(D) Include information to educate enrollees that health care
service plans that provide prescription drug benefits are required to
have a method for enrollees to obtain prescription drugs not listed
in the health plan drug formulary if the drugs are deemed medically
necessary by a clinician pursuant to Section 1367.24.
(E) Include information on which medications are covered,
including both generic and brand name.
(F) Include information on what tier of the plan's drug formulary
each medication is in.
(c) For purposes of this section, "formulary" means the complete
list of drugs preferred for use and eligible for coverage under a
health care service plan product and includes the drugs covered under
the pharmacy benefit of the product.
SEC. 7. SEC. 6. Section 10123.192 of
the Insurance Code is amended to read:
10123.192. (a) A health insurer that provides prescription drug
benefits and maintains one or more drug formularies shall do all of
the following:
(1) Post the formulary or formularies for each product offered by
the insurer on the insurer's Internet Web site in a manner that is
accessible and searchable by potential insureds, insureds, providers,
the general public, the department, and federal agencies as required
by federal law or regulations.
(2) Update the formularies posted pursuant to paragraph (1) with
any change to those formularies on a monthly basis.
(3) No later than six months after the date that a standard
formulary template is developed under subdivision (b), use that
template to display the formulary or formularies for each product
offered by the insurer.
(b) (1) By January 1, 2017, the department and the Department of
Managed Health Care shall jointly, and with input from interested
parties from at least one public meeting, develop a standard
formulary template for purposes of paragraph (3) of subdivision (a).
In developing the template, the department and Department of Managed
Health Care shall take into consideration existing requirements for
reporting of formulary information established by the federal Centers
for Medicare and Medicaid Services. To the extent feasible, in
developing the template, the department and the Department of Managed
Health Care shall evaluate a way to include on the template, in
addition to the information required to be included under paragraph
(2), cost-sharing information for drugs subject to coinsurance.
(2) The standard formulary template shall include a notification
that the presence of a drug on the insurer's formulary does not
guarantee that an insured will be prescribed that drug by his or her
prescribing provider for a particular medical condition. As applied
to a particular formulary for a product offered by an insurer, the
standard formulary template shall do all of the following:
(A) Include information on cost sharing
cost-sharing tiers and utilization controls, including prior
authorization or step therapy requirements, for each drug covered by
the product.
(B) Indicate any drugs on the formulary that are preferred over
other drugs on the formulary.
(C) Include information to educate insureds about the differences
between drugs administered or provided under a health insurer's
medical benefit and drugs prescribed under a health insurer's
prescription drug benefit and about how to obtain coverage
information about drugs that are not covered under the health insurer'
s prescription drug benefit.
(D) Include information to educate insureds that health insurers
that provide prescription drug benefits are required to have a method
for insureds to obtain prescription drugs not listed in the health
insurer's drug formulary if the drugs are deemed to be medically
necessary by a clinician pursuant to Section 1367.24 of the Health
and Safety Code, as required by clause (iv) of subparagraph (A) of
paragraph (2) of subdivision (a) of Section 10112.27.
(E) Include information on which medications are covered,
including both generic and brand name.
(F) Include information on what tier of the health insurer's drug
formulary each medication is in.
(c) The commissioner may adopt regulations as may be necessary to
carry out the purposes of this section. In adopting regulations, the
commissioner shall comply with Chapter 3.5 (commencing with Section
11340) of Part 1 of Division 3 of Title 2 of the Government Code.
(d) For purposes of this section, "formulary" means the complete
list of drugs preferred for use and eligible for coverage under a
health insurance product and includes the drugs covered under the
pharmacy benefit of the product.
SEC. 8. SEC. 7. Section 10123.193 is
added to the Insurance Code, to read:
10123.193. (a) The Legislature hereby finds and declares all of
the following:
(1) The federal Patient Protection and Affordable Care Act, its
implementing regulations and guidance, and related state law prohibit
discrimination based on a person's expected length of life, present
or predicted disability, degree of medical dependency, quality of
life, or other health conditions, including benefit designs that have
the effect of discouraging the enrollment of individuals with
significant health needs.
(2) The Legislature intends to build on existing state and federal
law to ensure that health coverage benefit designs do not have an
unreasonable discriminatory impact on chronically ill individuals,
and to ensure affordability of outpatient prescription drugs.
(3) Assignment of all or most prescription medications that treat
a specific medical condition to the highest cost tiers of a formulary
may effectively discourage enrollment by chronically ill
individuals, and may result in lower adherence to a prescription drug
treatment regimen.
(b) A nongrandfathered group policy of health insurance
that is offered, amended, or renewed on or after July 1, 2016, shall
comply with this section. A nongrandfathered individual
policy of health insurance that is offered, amended, or renewed on or
after January 1, 2017, shall comply with this section. The
cost-sharing limits established by this section apply only to
outpatient prescription drugs covered by the policy that constitute
essential health benefits, as defined by Section 10112.27.
(c) (1) A policy of health insurance that provides coverage for
outpatient prescription drugs shall cover medically necessary
prescription drugs. drugs, including
nonformulary drugs determined to be medically necessary consistent
with this part.
(2) A policy of health insurance that provides coverage for
outpatient prescription drugs shall cover a medically necessary
prescription drug for which there is not a therapeutic equivalent.
(2) If a nonformulary drug is authorized consistent with this
part, the cost sharing shall be the same as for a formulary drug.
(d) Copayments, coinsurance, and other cost sharing for outpatient
prescription drugs shall be reasonable so as to allow access to
medically necessary outpatient prescription drugs.
(e) (1) Consistent with federal law and
guidance, the formulary or formularies for outpatient prescription
drugs maintained by the health insurer shall not discourage the
enrollment of individuals with health conditions and shall not reduce
the generosity of the benefit for insureds with a particular
condition. condition in a manner that is not
based on a clinical indication or reasonable medical management
practices. Section 1342.7 of the Health and Safety Code
and any regulations adopted pursuant to that section shall be
interpreted in a manner that is consistent with this section.
(1)
( 2) For combination antiretroviral drug
treatments that are medically necessary for the treatment of
AIDS/HIV, a policy of health insurance shall cover a single-tablet
drug regimen that is as effective as a multitablet regimen unless,
consistent with clinical guidelines and peer-reviewed scientific and
medical literature, the multitablet regimen is clinically equally or
more effective and more likely to result in adherence to a drug
regimen.
(2) No more than 50 percent of drugs approved by the United States
Food and Drug Administration (FDA) that are in the same drug class
may be assigned to the two highest cost tiers of a drug formulary.
All health insurer formularies shall include at least one drug in the
lower cost tiers if all FDA-approved drugs in the same drug class
would otherwise qualify for the highest cost tiers and at least three
drugs in that class are available as FDA-approved drugs. The drug or
drugs assigned to the lower cost tiers pursuant to this paragraph
shall be the drug or drugs that were most often prescribed during the
immediately preceding plan year, based on the health insurer's
experience.
(3) A health insurer shall demonstrate to the
commissioner that any Any limitation or
utilization management is shall be
consistent with and based on clinical guidelines and peer-reviewed
scientific and medical literature.
(f) (1) With respect to an individual or group policy of health
insurance subject to Section 10112.28, the copayment, coinsurance, or
any other form of cost sharing for a covered outpatient prescription
drug for an individual prescription for a supply of up to 30 days
shall not exceed two hundred fifty dollars ($250), except as provided
in paragraphs (2) and (3).
(2) With respect to products with actuarial value at or equivalent
to the bronze level, cost sharing for a covered outpatient
prescription drug for an individual prescription for a supply of up
to 30 days shall not exceed five hundred dollars ($500).
($500), except as provided in paragraph (3).
(3) For a policy of health insurance that is a "high deductible
health plan" under the definition set forth in Section 223(c)(2) of
Title 26 of the United States Code, paragraph
paragraphs (1) and (2) of this subdivision shall
apply only once an insured's deductible has been satisfied for the
year.
(4) For a nongrandfathered individual or small group policy of
health insurance, the deductible for outpatient drugs, if any, shall
not exceed twice the amount specified in paragraph (1) or (2),
respectively.
(5) For purposes of paragraphs (1) and (2), "any other form of
cost sharing" shall not include deductible.
(g) (1) If a policy of health insurance maintains a drug formulary
grouped into tiers that includes a fourth tier or specialty
tier, a policy of health insurance shall use the following
definitions for each tier of the drug formulary:
(A) Tier one shall consist of most generic drugs and low-cost
preferred brand name drugs.
(B) Tier two shall consist of nonpreferred generic drugs,
preferred brand name drugs, and any other drugs recommended by the
health insurer's pharmacy and therapeutics committee based on
safety and efficacy and not solely based on the cost of the
prescription drug. safety, efficacy, and cost.
(C) Tier three shall consist of nonpreferred brand name drugs
or drugs that are recommended by the health insurer's pharmacy
and therapeutics committee based on safety and efficacy and
not solely based on the cost of the prescription drug, and which
safety, efficacy, and cost, or that generally
have a preferred and often less costly therapeutic alternative at a
lower tier.
(D) Tier four shall consist of drugs that are biologics, drugs
that the FDA or the manufacturer requires to be distributed through a
specialty pharmacy, drugs that require the insured to have special
training or clinical monitoring for self-administration, or drugs
that cost the health insurer more than six hundred dollars ($600) net
of rebates. rebates for a one-month supply.
(2) This section does not require a policy of health
insurance to include a fourth tier. A policy of health
insurance may maintain a drug formulary with fewer than four tiers.
(3) This section shall not be construed to limit a health insurer
from placing any drug in a lower tier.
(h) This section shall not be construed to require a health
insurer to impose cost sharing. This section shall not be construed
to require cost sharing for prescription drugs that state or federal
law otherwise requires to be provided without cost sharing.
(i) A policy of health insurance shall ensure that the placement
of prescription drugs on formulary tiers is based on clinically
indicated, reasonable medical management practices.
(j) In the provision of outpatient prescription drug coverage, a
health insurer may utilize formulary, prior authorization, step
therapy, or other reasonable medical management practices consistent
with this part.
(j)
( k) This section shall remain in effect
only until January 1, 2021, 2020, and
as of that date is repealed, unless a later enacted statute, that is
enacted before January 1, 2021, 2020,
deletes or extends that date.
SEC. 9. SEC. 8. Section 10123.193 is
added to the Insurance Code, to read:
10123.193. (a) The Legislature hereby finds and declares all of
the following:
(1) The federal Patient Protection and Affordable Care Act, its
implementing regulations and guidance, and related state law prohibit
discrimination based on a person's expected length of life, present
or predicted disability, degree of medical dependency, quality of
life, or other health conditions, including benefit designs that have
the effect of discouraging the enrollment of individuals with
significant health needs.
(2) The Legislature intends to build on existing state and federal
law to ensure that health coverage benefit designs do not have an
unreasonable discriminatory impact on chronically ill individuals,
and to ensure affordability of outpatient prescription drugs.
(3) Assignment of all or most prescription medications that treat
a specific medical condition to the highest cost tiers of a formulary
may effectively discourage enrollment by chronically ill
individuals, and may result in lower adherence to a prescription drug
treatment regimen.
(b) A nongrandfathered group policy of health insurance
that is offered, amended, or renewed on or after July 1, 2016, shall
comply with this section. A nongrandfathered individual
policy of health insurance that is offered, amended, or renewed on or
after January 1, 2017, shall comply with this section. The
cost-sharing limits established by this section apply only to
outpatient prescription drugs covered by the policy that constitute
essential health benefits, as defined by Section 10112.27.
(c) (1) A policy of health insurance that provides coverage for
outpatient prescription drugs shall cover medically necessary
prescription drugs. drugs, including
nonformulary drugs determined to be medically necessary consistent
with this part.
(2) A policy of health insurance that provides coverage for
outpatient prescription drugs shall cover a medically necessary
prescription drug for which there is not a therapeutic equivalent.
(2) If a nonformulary drug is authorized consistent with this
part, the cost sharing shall be the same as for a formulary drug.
(d) Copayments, coinsurance, and other cost sharing for outpatient
prescription drugs shall be reasonable so as to allow access to
medically necessary outpatient prescription drugs.
(e) (1) Consistent with federal law and
guidance, the formulary or formularies for outpatient prescription
drugs maintained by the health insurer shall not discourage the
enrollment of individuals with health conditions and shall not reduce
the generosity of the benefit for insureds with a particular
condition. condition in a manner
that is not based on a clinical indication or reasonable medical
management practices. Section 1342.7 of the Health and
Safety Code and any regulations adopted pursuant to that section
shall be interpreted in a manner that is consistent with this
section.
(1)
( 2) For combination antiretroviral drug
treatments that are medically necessary for the treatment of
AIDS/HIV, a policy of health insurance shall cover a single-tablet
drug regimen that is as effective as a multitablet regimen unless,
consistent with clinical guidelines and peer-reviewed scientific and
medical literature, the multitablet regimen is clinically equally or
more effective and more likely to result in adherence to a drug
regimen.
(2) No more than 50 percent of drugs approved by the United States
Food and Drug Administration (FDA) that are in the same drug class
may be assigned to the two highest cost tiers of a drug formulary.
All health insurer formularies shall include at least one drug in the
lower cost tiers if all FDA-approved drugs in the same drug class
would otherwise qualify for the highest cost tiers and at least three
drugs in that class are available as FDA-approved drugs. The drug or
drugs assigned to the lower cost tiers pursuant to this paragraph
shall be the drug or drugs that were most often prescribed during the
immediately preceding plan year, based on the health insurer's
experience.
(3) A health insurer shall demonstrate to the commissioner thatany
(3) Any limitation or utilization
management is shall be consistent with
and based on clinical guidelines and peer-reviewed scientific and
medical literature.
(f) (1) If a policy of health insurance maintains a drug formulary
grouped into tiers that includes a fourth tier or specialty tier, a
policy of health insurance shall use the following definitions for
each tier of the drug formulary:
(A) Tier one shall consist of most generic drugs and low-cost
preferred brand drugs.
(B) Tier two shall consist of nonpreferred generic drugs,
preferred brand name drugs, and any other drugs recommended by the
health insurer's pharmacy and therapeutics committee based on safety
and efficacy and not solely based on the cost of the prescription
drug.
(C) Tier three shall consist of nonpreferred brand name drugs that
are recommended by the health insurer's pharmacy and therapeutics
committee based on safety and efficacy and not solely based on the
cost of the prescription drug, and which generally have a preferred
and often less costly therapeutic alternative at a lower tier.
(D) Tier four shall consist of drugs that are biologics, drugs
that the FDA or the manufacturer requires to be distributed through a
specialty pharmacy, drugs that require the insured to have special
training or clinical monitoring for self-administration, or drugs
that cost the health insurer more than six hundred dollars ($600) net
of rebates.
(2) This section does not require a policy of health insurance to
include a fourth tier. A
(f) (1) A
policy of health insurance may maintain a drug formulary with fewer
than four tiers.
(2) This section shall not be construed to limit a health insurer
from placing any drug in a lower tier.
(g) This section shall not be construed to require a health
insurer to impose cost sharing. This section shall not be construed
to require cost sharing for prescription drugs that state or federal
law otherwise requires to be provided without cost sharing.
(h) A policy of health insurance shall ensure that the placement
of prescription drugs on formulary tiers is based on clinically
indicated, reasonable medical management practices.
(i) In the provision of outpatient prescription drug coverage, a
health insurer may utilize formulary, prior authorization, step
therapy, or other reasonable medical management practices consistent
with this part.
(i)
( j) This section shall become operative on
January 1, 2021. 2020.
SEC. 10. SEC. 9. Section 10123.201
is added to the Insurance Code, to read:
10123.201. (a) (1)
Every health insurer that provides prescription drug benefits shall
maintain an expeditious process by which prescribing providers may
obtain authorization for a medically necessary nonformulary
prescription drug. On or before July 1, 2016, every insurer that
provides prescription drug benefits shall file with the commissioner
a description of its process for responding to authorization requests
for nonformulary drugs. Any changes to this process shall be filed
with the commissioner. The insurer shall provide that the insured,
the insured's designee, or the insured's prescribing provider may
seek an authorization for a nonformulary prescription drug.
A policy of health insurance that covers outpatient
prescription drugs shall cover medically necessary drugs. The policy
may provide for step therapy and prior authorization consistent with
Section 1342.7 of the Health and Safety Code and any regulations
adopted pursuant to that section.
(2) Each insurer shall respond to an authorization request within
72 hours following receipt of the authorization request for a
nonurgent authorization. If the insurer grants the authorization
request, the insurer shall provide coverage of the nonformulary drug
for the duration of the prescription, including refills.
(3) Each insurer shall provide that an urgent authorization may be
obtained within 24 hours if an insured is suffering from a health
condition that may seriously jeopardize the insured's life, health,
or ability to regain maximum function, or if an insured is undergoing
a current course of treatment using a nonformulary prescription
drug. An insurer that grants
an exception based on these urgent circumstances shall provide
coverage of the nonformulary prescription drug for the duration of
that urgent condition.
(4) If an insurer imposes step therapy, the insurer shall provide
an expeditious process to authorize an exception to step therapy when
medically necessary and to conform effectively and efficiently with
continuity of care requirements of this part and federal law, and any
regulations issued thereunder. The process to authorize an exception
to step therapy shall be consistent with this section, including the
timelines provided in this section.
(5) Each insurer shall provide a written description of its most
current process to its prescribing providers. For purposes of this
section, a prescribing provider shall include a provider authorized
to write a prescription, pursuant to subdivision (a) of Section 4040
of the Business and Professions Code, to treat a medical condition of
an insured.
(b) Any insurer that disapproves a request made pursuant to
subdivision (a) by a prescribing provider to obtain authorization for
a nonformulary drug shall provide the reasons for the disapproval in
a notice provided to the insured. The notice shall indicate that the
insured may file a grievance complaint
with the insurer if the insured objects to the disapproval,
including any alternative drug or treatment offered by the insurer.
The notice shall comply with Section 10133.661.
(c) (1) Commencing January 1, 2017, an insurer shall maintain a
pharmacy and therapeutics committee that shall be responsible for
developing, maintaining, and overseeing any drug formulary list. If
the insurer delegates responsibility for the formulary to any entity,
the obligation of the insurer to comply with this part shall not be
waived.
(2) The pharmacy and therapeutics committee board membership shall
conform with both of the following:
(A) Represent a sufficient number of clinical specialties to
adequately meet the needs of insureds.
(B) Consist of a majority of individuals who are practicing
physicians, practicing pharmacists, and other practicing health
professionals who are licensed to prescribe drugs.
(3) Members of the board shall abstain from voting on any issue in
which the member has a conflict of interest with respect to the
issuer or a pharmaceutical manufacturer.
(4) At least 20 percent of the board membership shall not have a
conflict of interest with respect to the issuer or any pharmaceutical
manufacturer.
(5) The pharmacy and therapeutics committee shall meet at least
quarterly and shall maintain written documentation of the rationale
for its decisions regarding the development of, or revisions to, the
formulary drug list.
(6) The pharmacy and therapeutics committee shall do all of the
following:
(A) Develop and document procedures to ensure appropriate drug
review and inclusion.
(B) Base clinical decisions on the strength of the scientific
evidence and standards of practice, including assessing peer-reviewed
medical literature, pharmacoeconomic studies, outcomes research
data, and other related information.
(C) Consider the therapeutic advantages of drugs in terms of
safety and efficacy when selecting formulary drugs.
(D) Review policies that guide exceptions and other utilization
management processes, including drug utilization review, quantity
limits, and therapeutic interchange.
(E) Evaluate and analyze treatment protocols and procedures
related to the insurer's formulary at least annually.
(F) Review and approve all clinical prior authorization criteria,
step therapy protocols, and quantity limit restrictions applied to
each covered drug.
(G) Review new United States Food and Drug Administration-approved
drugs and new uses for existing drugs.
(H) Ensure the insurer's formulary drug list or lists cover a
range of drugs across a broad distribution of therapeutic categories
and classes and recommended drug treatment regimens that treat all
disease states and does not discourage enrollment by any group of
insureds.
(I) Ensure the insurer's formulary drug list or lists provide
appropriate access to drugs that are included in broadly accepted
treatment guidelines and that are indicative of general best
practices at the time.
(7) This subdivision shall be interpreted consistent with federal
guidance issued under paragraph (3) of subdivision (a) of Section
156.122 of Title 45 of the Code of Federal Regulations. This
subdivision shall apply to the individual, small group, and large
group markets.
(d) (1) A health insurer may impose prior authorization
requirements on prescription drug benefits, consistent with the
requirements of this part.
(2) (A) When there is more than one drug that is appropriate for
the treatment of a medical condition, a health insurer may require
step therapy. A health insurer that requires step therapy
shall comply with the requirements specified in paragraph (4) of
subdivision (a).
(B) In circumstances where an insured is changing policies, the
new policy shall not require the insureds to repeat step therapy when
that insured is already being treated for a medical condition by a
prescription drug provided that the drug is appropriately prescribed
and is considered safe and effective for the insured's condition.
Nothing in this section shall preclude the new policy from imposing a
prior authorization requirement pursuant to subdivision (a) for the
continued coverage of a prescription drug prescribed pursuant to step
therapy imposed by the former policy, or preclude the prescribing
provider from prescribing another drug covered by the new policy that
is medically appropriate for the insured.
(3) An insurer shall provide coverage for the medically necessary
dosage and quantity of the drug prescribed for the treatment of a
medical condition consistent with professionally recognized standards
of practice.
(4) An For plan years
commencing on or after January 1, 2017, an insurer that
provides essential health benefits shall allow an insured to access
prescription drug benefits at an in-network retail pharmacy unless
the prescription drug is subject to restricted distribution by the
United States Food and Drug Administration or requires special
handling, provider coordination, or patient education that cannot be
provided by a retail pharmacy. An insurer that provides essential
health benefits may charge an insured a different cost sharing for
obtaining a covered drug at a retail pharmacy, but all cost sharing
shall count toward the policy's annual limitation on cost sharing
consistent with Section 10112.28.
(e) The process described in subdivision (a) by which insureds may
obtain medically necessary nonformulary drugs, including specified
timelines for responding to prescribing provider authorization
requests, shall be described in evidence of coverage and disclosure
forms, as required by Section 10603, issued on or after January 1,
2016.
(f)
( e) Every health insurer that provides
prescription drug benefits shall maintain all of the following
information, which shall be made available to the commissioner upon
request:
(1) The complete drug formulary or formularies of the insurer, if
the insurer maintains a formulary, including a list of the
prescription drugs on the formulary of the insurer by major
therapeutic category with an indication of whether any drugs are
preferred over other drugs.
(2) Records developed by the pharmacy and therapeutic committee of
the insurer, or by others responsible for developing, modifying, and
overseeing formularies, including medical groups, individual
practice associations, and contracting pharmaceutical benefit
management companies, used to guide the drugs prescribed for the
insureds of the insurer, that fully describe the reasoning behind
formulary decisions.
(3) Any insurer arrangements with prescribing providers, medical
groups, individual practice associations, pharmacists, contracting
pharmaceutical benefit management companies, or other entities that
are associated with activities of the insurer to encourage formulary
compliance or otherwise manage prescription drug benefits.
(g)
( f) If an insurer provides prescription
drug benefits, the commissioner shall, as part of its market conduct
examination, review the performance of the insurer in providing those
benefits, including, but not limited to, a review of the procedures
and information maintained pursuant to this section, and describe the
performance of the insurer as part of its report issued as part of
its market conduct examination.
(h)
( g) The commissioner shall not publicly
disclose any information reviewed pursuant to this section that is
determined by the commissioner to be confidential pursuant to state
law.
(i)
( h) For purposes of this section, the
following definitions shall apply:
(1) "Authorization" means approval by the health insurer to
provide payment for the prescription drug.
(2) "Step therapy" means a type of protocol that specifies the
sequence in which different prescription drugs for a given medical
condition and medically appropriate for a particular patient are to
be prescribed.
(j)
( i) (1) Nonformulary prescription drugs
shall include any drug for which an insured's copayment or
out-of-pocket costs are different than the copayment for a formulary
prescription drug, except as otherwise provided by law or regulation.
(2) If a nonformulary drug is authorized consistent with this
section, the cost sharing shall be the same as for a formulary drug
consistent with, until January 1, 2021, 2020,
subdivision (f) of Section 10123.193.
(k)
( j) Nothing in this section shall be
construed to affect an insured's or policyholder's eligibility to
submit a complaint to the department for review or to apply to the
department for an independent medical review.
review under Article 3.5 (commencing with Section 10169).
(l)
( k) Nothing in this section shall be
construed to restrict or impair the application of any other
provision of this part.
SEC. 11. SEC. 10. No reimbursement
is required by this act pursuant to Section 6 of Article XIII B of
the California Constitution because the only costs that may be
incurred by a local agency or school district will be incurred
because this act creates a new crime or infraction, eliminates a
crime or infraction, or changes the penalty for a crime or
infraction, within the meaning of Section 17556 of the Government
Code, or changes the definition of a crime within the meaning of
Section 6 of Article XIII B of the California Constitution.