Today's Law As Amended


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AB-752 Prescription drug coverage.(2021-2022)



As Amends the Law Today


SECTION 1.

 Section 1367.207 is added to the Health and Safety Code, to read:

1367.207.
 (a) Upon request of an enrollee or an enrollee’s health care provider, a health care service plan shall furnish all of the following information regarding a prescription drug to the enrollee or the enrollee’s health care provider:
(1) The enrollee’s eligibility for the prescription drug.
(2) A full formulary list of drugs that are covered under the enrollee’s health care service plan contract.
(3) Cost sharing information for the drug and other formulary alternatives, including a description of any variance in cost sharing based on the dispensing pharmacy, whether retail or mail order, or the health care provider.
(4) Applicable utilization management requirements for the drug or other formulary alternatives, including prior authorization, step therapy, quantity limits, and site-of-service restrictions.
(b) (1) A health care service plan shall respond in real time to a request made pursuant to subdivision (a) in the same format in which the request was made.
(2) A health care service plan shall allow the use of an interoperability element to provide the information required pursuant to subdivision (a) in the same format as the request.
(c) (1) A health care service plan shall ensure that the information provided pursuant to subdivision (a) is current no later than one business day after a change is made and is provided in real time.
(2) A health care service plan shall provide the information pursuant to subdivision (a) if the request is made using the drug’s unique billing code or a descriptive term, including the brand name or generic name of the drug. A health care service plan shall not deny or delay a response to a request for the purpose of blocking the release of information based on how the information was requested.
(d) A health care service plan shall not do any of the following:
(1) Restrict, prohibit, or otherwise hinder a health care provider from communicating or sharing any of the following:
(A) The information provided pursuant to subdivision (a).
(B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the enrollee’s health care service plan contract.
(C) Information about the cash price of the drug.
(2) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a), which includes, but is not limited to, charging fees for access to the information, not responding to a request at the time made if a response is reasonably possible, or instituting enrollee consent requirements.
(3) Penalize a health care provider for disclosing the information provided pursuant to subdivision (a).
(4) Penalize a health care provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.
(e) For purposes of this section:
(1) “Cost sharing information” means the actual out-of-pocket amount an enrollee would be required to pay a dispensing pharmacy or health care provider for a prescription drug under the terms of the enrollee’s health care service plan contract.
(2) “Health care provider” means a person licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.
(3) “Interoperability element” means hardware, software, integrated technologies or related licenses, technical information, privileges, rights, intellectual property, upgrades, or services necessary to provide a response to an enrollee, an enrollee’s health care provider, or a third party acting on behalf of a provider.

SEC. 2.

 Section 10123.204 is added to the Insurance Code, to read:

10123.204.
 (a) Upon request of an insured or insured’s health care provider, a health insurer shall furnish all of the following information regarding a prescription drug to the insured or the insured’s health care provider:
(1) The insured’s eligibility for the prescription drug.
(2) A full formulary list of drugs that are covered under the insured’s health insurance policy.
(3) Cost sharing information for the drug and other formulary alternatives, including a description of any variance in cost sharing based on the dispensing pharmacy, whether retail or mail order, or the health care provider.
(4) Applicable utilization management requirements for the drug or other formulary alternatives, including prior authorization, step therapy, quantity limits, and site-of-service restrictions.
(b) (1) A health insurer shall respond in real time to a request made pursuant to subdivision (a) in the same format in which the request was made.
(2) A health insurer shall allow the use of an interoperability element to provide the information required pursuant to subdivision (a) in the same format as the request.
(c) (1) A health insurer shall ensure that the information provided pursuant to subdivision (a) is current no later than one business day after a change is made and is provided in real time.
(2) A health insurer shall provide the information pursuant to subdivision (a) if the request is made using the drug’s unique billing code or a descriptive term, including the brand name or generic name of the drug. A health insurer shall not deny or delay a response to a request for the purpose of blocking the release of information based on how the information was requested.
(d) A health insurer shall not do any of the following:
(1) Restrict, prohibit, or otherwise hinder a health care provider from communicating or sharing any of the following:
(A) The information provided pursuant to subdivision (a).
(B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the insured’s health insurance policy.
(C) Information about the cash price of the drug.
(2) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a), which includes, but is not limited to, charging fees for access to the information, not responding to a request at the time made if a response is reasonably possible, or instituting enrollee consent requirements.
(3) Penalize a health care provider for disclosing the information provided pursuant to subdivision (a).
(4) Penalize a health care provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.
(e) For purposes of this section:
(1) “Cost sharing information” means the actual out-of-pocket amount an insured would be required to pay a dispensing pharmacy or health care provider for a prescription drug under the terms of the insured’s policy.
(2) “Health care provider” means a person licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.
(3) “Interoperability element” means hardware, software, integrated technologies or related licenses, technical information, privileges, rights, intellectual property, upgrades, or services necessary to provide a response to an insured, an insured’s health care provider, or a third party acting on behalf of a provider.
SEC. 3.
 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.