Bill Text: CA AB2352 | 2021-2022 | Regular Session | Amended

California Assembly Bill 2352 (Prior Session Legislation)

NOTE: There are more recent revisions of this legislation. Read Latest Draft

Bill Title: Prescription drug coverage.

Spectrum: Bipartisan Bill

Status: (Passed) 2022-09-27 - Chaptered by Secretary of State - Chapter 590, Statutes of 2022. [AB2352 Detail]

Download: California-2021-AB2352-Amended.html

Amended IN Senate June 20, 2022

Amended IN Assembly April 06, 2022

CALIFORNIA LEGISLATURE— 2021–2022 REGULAR SESSION

Assembly Bill

No. 2352

Introduced by Assembly Member Nazarian
(Coauthor: Assembly Member Waldron)

February 16, 2022

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 2352, 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 the applicable deductible.

This bill would require a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies to furnish specified information about a prescription drug upon request by an enrollee or insured, or their prescribing provider. The bill would require the plan or insurer to respond in real time to that request and ensure the information is current no later than one business day after a change is made. The bill would prohibit a health care service plan or health insurer from, among other things, restricting a prescribing 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) A health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:

(1) Upon request of an enrollee or an enrollee’s prescribing provider, furnish all of the following information regarding a prescription drug to the enrollee or the enrollee’s prescribing health care provider:

(A) The enrollee’s eligibility for the prescription drug.

(B) A full formulary list of drugs that are covered under the enrollee’s health care service plan contract.

(C) Cost-sharing information for the drug and other formulary alternatives, including any variance in cost sharing based on the dispensing pharmacy, whether retail or mail order, or the health care provider.

(D) Applicable utilization management requirements for the drug or other formulary alternatives.

(2) Respond in real time to a request made pursuant to paragraph (1) through a standard API.

(3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1).

(4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time.

(5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code.

(b) A health care service plan shall not do any of the following:

(1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a).

(2) Restrict, prohibit, or otherwise hinder a prescribing provider from communicating or sharing to an enrollee 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.

(3) 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 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.

(4) Penalize a prescribing provider for disclosing the information provided pursuant to subdivision (a).

(5) Penalize a prescribing provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.

(1) “Cost-sharing information” means the actual out-of-pocket amount an enrollee would be required to pay a dispensing pharmacy or prescribing provider for a prescription drug under the terms of the enrollee’s health care service plan contract.

(2) “Interoperability element” means integrated technologies or services necessary to provide a response to an enrollee or an enrollee’s prescribing provider.

(3) “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee.

(4) “Standard API” means an application interface that is standardized for vendors to conform to in order to access the ~~information.~~ information pursuant to Section 170.215 of Title 45 of the Code of Federal Regulations.

(d) This bill shall not be construed to authorize further disclosure inconsistent with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Public Law 104-191) and the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code).

SEC. 2.

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

10123.204.

(a) A health insurer that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:

(1) Upon request of an insured or an insured’s prescribing provider, furnish all of the following information regarding a prescription drug to the insured or the insured’s prescribing health care provider:

(A) The insured’s eligibility for the prescription drug.

(B) A full formulary list of drugs that are covered under the insured’s health insurance policy.

(D) Applicable utilization management requirements for the drug or other formulary alternatives.

(2) Respond in real time to a request made pursuant to paragraph (1) through a standard API.

(3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1).

(4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time.

(5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code.

(b) A health insurer shall not do any of the following:

(1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a).

(2) Restrict, prohibit, or otherwise hinder a prescribing provider from communicating or sharing to an enrollee 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.

(4) Penalize a prescribing provider for disclosing the information provided pursuant to subdivision (a).

(5) Penalize a prescribing provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.

(1) “Cost-sharing information” means the actual out-of-pocket amount an insured would be required to pay a dispensing pharmacy or prescribing provider for a prescription drug under the terms of the insured’s health insurance policy.

(2) “Interoperability element” means integrated technologies or services necessary to provide a response to an insured or an insured’s prescribing provider.

(3) “Prescribing provider” is a health care provider authorized to write a prescription to treat a medical condition for a health plan enrollee.

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.