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

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Date Published: 04/15/2021 09:00 PM
AB752:v96#DOCUMENT

Amended  IN  Assembly  April 15, 2021
Amended  IN  Assembly  March 30, 2021
Amended  IN  Assembly  March 18, 2021

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill
No. 752


Introduced by Assembly Member Nazarian
(Coauthors: Assembly Members Bonta and Waldron)
(Coauthor: Senator Wiener)

February 16, 2021


An act to add Section 1367.207 to the Health and Safety Code, and to add Section 10123.204 to the Insurance Code, relating to health care coverage.


LEGISLATIVE COUNSEL'S DIGEST


AB 752, as amended, Nazarian. Prescription drug coverage.
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 provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan contract or health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs and subjects those policies to certain limitations on cost sharing and the placement of drugs on formularies. Existing law limits the maximum amount an enrollee or insured may be required to pay at the point of sale for a covered prescription drug to the lesser of the applicable cost-sharing amount or the retail price, and requires that payment to apply to any applicable deductible.
This bill would require a health care service plan or health insurer, or an entity acting on its behalf, insurer to furnish specified information about a prescription drug upon request by an enrollee or insured, insured or their health care provider, or a third party acting on their behalf. provider. The bill would set forth requirements for the request and response, including that they comply with established industry content and transport standards. require a health care service plan or health insurer to, among other things, respond in real time to a request for the above-described information. The bill would prohibit a health care service plan or health insurer from from, among other things, restricting a health care provider from sharing the information furnished about the prescription drug or penalizing a provider for prescribing a lower cost drug. Because a willful violation of these provisions by a health care service plan would be a crime, the 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   Local Program: YES  

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


SECTION 1.

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

1367.207.
 (a) Upon request of an enrollee, an enrollee’s health care provider, or a third party acting on behalf of an enrollee, a health care service plan or an entity acting on behalf of a health care service plan, including an affiliate or a pharmacy benefit manager, 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, enrollee or the enrollee’s health care provider, or the third party acting on behalf of the enrollee: 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 or an entity acting on its behalf shall respond shall respond in real time to a request made pursuant to subdivision (a) in the same format in which the request was made.

(1)A request and the response to that request shall comply with established industry content and transport standards published by either of the following:

(A)A standards developing organization accredited by the American National Standards Institute, including the National Council for Prescription Drug Programs, Accredited Standards Committee X12, or Health Level Seven International.

(B)A relevant federal or state governing body, including the federal Centers for Medicare and Medicaid Services or the Office of the National Coordinator for Health Information Technology.

(2)A facsimile or the use of a proprietary payer or patient portal shall not be an acceptable form for a request or the response to that request.

(3)

(2) A health care service plan or an entity acting on its behalf may use 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 or an entity acting on its behalf 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 or entity acting on its behalf 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 or an entity acting on its behalf 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 or entity acting on its behalf 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)Additional payment or cost sharing information that may reduce the enrollee’s out-of-pocket costs, including cash price or patient assistance and support programs sponsored by a drug manufacturer, foundation, or other entity.

(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 may include 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, implementing technology in nonstandard ways, or instituting enrollee consent requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using the information provided pursuant to subdivision (a). 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)A health care service plan or entity acting on its behalf shall treat a third party acting on behalf of an enrollee as an enrollee if the third party has the authority to make health care decisions on behalf of an enrollee.

(f)

(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 an enrollee. a provider.

SEC. 2.

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

10123.204.
 (a) Upon request of an insured, an insured’s health care provider, or a third party acting on behalf of an insured, a health insurer or an entity acting on behalf of a health insurer, including an affiliate or a pharmacy benefit manager, insured or insured’s health care provider, a health insurer shall furnish all of the following information regarding a prescription drug to the insured, insured or the insured’s health care provider, or the third party acting on behalf of the insured: 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 or an entity acting on its behalf shall respond shall respond in real time to a request made pursuant to subdivision (a) in the same format in which the request was made.

(1)A request and the response to that request shall comply with established industry content and transport standards published by either of the following:

(A)A standards developing organization accredited by the American National Standards Institute, including the National Council for Prescription Drug Programs, Accredited Standards Committee X12, or Health Level Seven International.

(B)A relevant federal or state governing body, including the federal Centers for Medicare and Medicaid Services or the Office of the National Coordinator for Health Information Technology.

(2)A facsimile or the use of a proprietary payer or patient portal shall not be an acceptable form for a request or the response to that request.

(3)

(2) A health insurer or an entity acting on its behalf may use 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 or an entity acting on its behalf 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 or entity acting on its behalf 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 or an entity acting on its behalf 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 or entity acting on its behalf 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)Additional payment or cost sharing information that may reduce the insured’s out-of-pocket costs, including cash price or patient assistance and support programs sponsored by a drug manufacturer, foundation, or other entity.

(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 may include 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, implementing technology in nonstandard ways, or instituting insured consent requirements, processes, policies, procedures, or renewals that are likely to substantially increase the complexity or burden of accessing, exchanging, or using the information provided pursuant to subdivision (a). 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)A health insurer or entity acting on its behalf shall treat a third party acting on behalf of an insured as an insured if the third party has the authority to make health care decisions on behalf of an insured.

(f)

(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 an insured. 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.