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.