10176.61.
(a) An insurer issuing, amending, delivering, or renewing a disability insurance policy on or after January 1, 2000, that covers hospital, medical, or surgical expenses shall include coverage for the following equipment and supplies for the management and treatment of insulin-using diabetes, non-insulin-using diabetes, and gestational diabetes as medically necessary, even if the items are available without a prescription:(1) Blood glucose monitors and blood glucose testing strips.
(2) Blood glucose monitors designed to assist the visually impaired.
(3) Insulin pumps and all related necessary supplies.
(4) Ketone urine testing strips.
(5) Lancets and lancet puncture devices.
(6) Pen delivery systems for the administration of insulin.
(7) Podiatric devices to prevent or treat diabetes-related complications.
(8) Insulin syringes.
(9) Visual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin.
(b) An insurer issuing, amending,
delivering, or renewing a disability insurance policy on or after January 1, 2000, that covers prescription benefits shall include coverage for the following prescription items if the items are determined to be medically necessary:
(1) Insulin. For a disability insurance policy issued, amended, delivered, or renewed on or after January 1, 2024, that covers prescription benefits, coverage shall include all dosage forms and concentrations of at least two insulins for each insulin drug type, within the insulin class, of the relevant United States Pharmacopeia therapeutic category. If there is only one insulin for a given drug type, then only one insulin, in all dosage forms and concentrations, shall be covered.
(2) Prescriptive
medications for the treatment of diabetes.
(3) Glucagon.
(c) The coinsurances and deductibles for the benefits specified in subdivisions (a) and (b) shall not exceed those established for similar benefits within the given policy.
(d) (1) Notwithstanding subdivision (c), a disability insurance policy that is issued, amended, or renewed on or after January 1, 2024, or a policy offered in the individual or small group market on or after January 1, 2025, shall not impose a
copayment, coinsurance, deductible, or other out-of-pocket expense on an insulin prescription drug that exceeds thirty-five dollars ($35) for a 30-day supply.
(2) If a disability insurance policy for an individual or small group product maintains a drug formulary grouped into tiers, as long as there are at least two insulins of each drug type, in all forms and
concentrations, on a preferred tier, the out-of-pocket cap of not more than thirty-five dollars ($35) for a 30-day supply, pursuant to paragraph (1), shall apply only to insulin prescription drugs that are in Tier 1 and Tier 2. If there is only one insulin for a given drug type, then, as to that insulin, this requirement shall be met by placing that one insulin on Tier 1 or Tier 2. For purposes of this paragraph, “drug type” means rapid acting, rapid acting inhaled, regular or short acting, intermediate acting, long acting, ultra-long acting, and premixed.
(3) If a policy is a “high deductible health plan” under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code, the policy shall not impose a deductible, coinsurance, or any other cost
sharing on an insulin prescription drug, unless not applying the deductible, coinsurance, or any other cost sharing to an insulin prescription drug would conflict with federal requirements for high deductible health plans.
(4) For purposes of this subdivision, “insulin prescription drug” means a prescription drug product that contains insulin and is used to control blood glucose levels to treat diabetes.
(e) An insurer shall provide coverage for diabetes outpatient
self-management training, education, and medical nutrition therapy necessary to enable an insured to properly use the equipment, supplies, and medications set forth in subdivisions (a) and (b) and additional diabetes outpatient self-management training, education, and medical nutrition therapy upon the direction or prescription of those services by the insured’s participating physician. If an insurer delegates outpatient self-management training to contracting providers, the insurer shall require contracting providers to ensure that diabetes outpatient self-management training, education, and medical nutrition therapy are provided by appropriately licensed or registered health care professionals.
(f) The diabetes outpatient self-management training, education, and medical nutrition therapy services identified in subdivision
(e) shall be provided by appropriately licensed or registered health care professionals as prescribed by a health care professional legally authorized to prescribe the services.
(g) The coinsurances and deductibles for the benefits specified in subdivision (e) shall not exceed those established for physician office visits by the insurer.
(h) Every disability insurer governed by this section shall disclose the benefits covered pursuant to this section in the insurer’s evidence of coverage and disclosure forms.
(i) An insurer shall not reduce or eliminate coverage as a result of this section.
(j) This section does not apply to vision-only,
dental-only, accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, or disability income insurance, except that for accident-only, specified disease, and hospital indemnity insurance coverage, benefits under this section only apply to the extent that the benefits are covered under the general terms and conditions that apply to all other benefits under the policy. This section does not impose a new benefit mandate on accident-only, specified disease, or hospital indemnity insurance.