Bill Text: CA SB1021 | 2017-2018 | Regular Session | Amended
Bill Title: Prescription drugs.
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Passed) 2018-09-26 - Chaptered by Secretary of State. Chapter 787, Statutes of 2018. [SB1021 Detail]
Download: California-2017-SB1021-Amended.html
Amended
IN
Senate
May 01, 2018 |
Amended
IN
Senate
April 16, 2018 |
Senate Bill | No. 1021 |
Introduced by Senator Wiener (Principal coauthor: Senator Atkins) |
February 07, 2018 |
LEGISLATIVE COUNSEL'S DIGEST
Digest Key
Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YESBill Text
The people of the State of California do enact as follows:
SECTION 1.
Section 1342.71 of the Health and Safety Code, as amended by Section 175 of Chapter 86 of the Statutes of 2016, is amended to read:1342.71.
(a) The Legislature hereby finds and declares all of the following:(e)(1)With respect to an individual or group health care service plan contract subject to Section 1367.006, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed two
hundred fifty dollars ($250), except as provided in paragraphs (2) and (3).
(2)With respect to products with actuarial value at, or equivalent to, the bronze level, cost sharing for a covered outpatient
prescription drug for an individual prescription for a supply of up to 30 days shall not exceed five hundred dollars ($500), except as provided in paragraph (3).
(3)For a health care service plan contract that is a “high deductible health plan” under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code, paragraphs (1) and (2) of this subdivision shall apply only once an enrollee’s deductible has been satisfied for the year.
(4)For a nongrandfathered individual or small group health care service plan contract, the annual deductible for outpatient drugs, if any, shall not exceed twice the amount specified in paragraph (1) or (2), respectively.
(5)For purposes of paragraphs
(1) and (2), “any other form of cost sharing” shall not include a deductible.
(f)(1)If a health care service plan contract for a nongrandfathered individual or small group product maintains a drug formulary grouped into tiers that includes a fourth tier, a health care service plan contract shall use the following definitions for each tier of the drug formulary:
(A)Tier one shall consist of most generic drugs and low-cost preferred brand name drugs.
(B)Tier two shall consist of nonpreferred generic drugs, preferred brand name drugs, and any other drugs recommended by the health care service plan’s pharmacy and therapeutics committee based on safety, efficacy, and cost.
(C)Tier three shall consist of nonpreferred brand name drugs or drugs that are recommended by the health care service plan’s pharmacy and therapeutics committee based on safety, efficacy, and cost, or that generally have a preferred and often less costly therapeutic alternative at a lower tier.
(D)Tier four shall consist of drugs that are biologics, drugs that the FDA or the manufacturer requires to be distributed through a specialty pharmacy, drugs that require the enrollee to have special training or clinical monitoring for self-administration, or drugs that cost the health plan more than six hundred dollars ($600) net of rebates for a one-month supply.
(2)In placing specific drugs on specific tiers, or choosing to place
a drug on the formulary, the health care service plan shall take into account the other provisions of this section and this chapter.
(3)A health care service plan contract may maintain a drug formulary with fewer than four tiers. A health care service plan contract shall not maintain a drug formulary with more than four tiers.
(4)This section shall not be construed to limit a health care service plan from placing any drug in a lower tier. If a biologic has a therapeutic equivalent, consistent with state law, it may be placed on a tier other than tier four.
(g)
(h)
(i)
(j)
SEC. 2.
Section 1342.71 of the Health and Safety Code, as added by Section 2 of Chapter 619 of the Statutes of 2015, is repealed.SEC. 3.
Section 1342.72 is added to the Health and Safety Code, to read:1342.72.
(a) For combination antiretroviral drug treatments that are medically necessary for the prevention of AIDS/HIV, a health care service plan contract shall cover a single-tablet drug regimen that is as effective as a multitablet regimen unless, consistent with clinical guidelines and peer-reviewed scientific and medical literature, the multitablet regimen is clinically equally or more effective and more likely to result in adherence to a drug regimen.SEC. 4.
Section 1342.73 is added to the Health and Safety Code, to read:1342.73.
(a) (1) With respect to an individual or group health care service plan contract subject to Section 1367.006, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed two hundred fifty dollars ($250), except as provided in paragraphs (2) and (3).SEC. 3.SEC. 5.
Section 10123.193 of the Insurance Code,
as amended by Section 204 of Chapter 86 of the Statutes of 2016, is amended to read:10123.193.
(a) The Legislature hereby finds and declares all of the following:(f)(1)With respect to an individual or group policy of health insurance subject to Section 10112.28, the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed two hundred fifty dollars ($250), except as provided in paragraphs (2) and (3).
(2)With respect to products with actuarial value at or equivalent to the bronze level, cost sharing for a covered outpatient prescription drug for an individual prescription for a supply of up to 30 days shall not exceed five hundred dollars ($500), except as provided in paragraph (3).
(3)For a policy of health insurance that is a “high deductible health plan” under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code, paragraphs (1) and (2) of this subdivision applies only once an insured’s deductible has been satisfied for the year.
(4)For a nongrandfathered individual or small group policy of health insurance, the annual deductible for outpatient drugs, if any, shall not exceed twice the amount specified in paragraph (1) or (2), respectively.
(5)For purposes of paragraphs (1) and (2), “any other form of cost sharing” shall not include a deductible.
(g)(1)If a policy of health insurance offered, sold, or renewed in the
nongrandfathered individual or small group market maintains a drug formulary grouped into tiers that includes a fourth tier, a policy of health insurance shall use the following definitions for each tier of the drug formulary:
(A)Tier one shall consist of most generic drugs and low-cost preferred brand name drugs.
(B)Tier two shall consist of nonpreferred generic drugs, preferred brand name drugs, and any other drugs recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost.
(C)Tier three shall consist of nonpreferred brand name drugs or drugs that are recommended by the health insurer’s pharmacy and therapeutics committee based on safety, efficacy, and cost, or that
generally have a preferred and often less costly therapeutic alternative at a lower tier.
(D)Tier four shall consist of drugs that are biologics, drugs that the FDA or the manufacturer requires to be distributed through a specialty pharmacy, drugs that require the insured to have special training or clinical monitoring for self-administration, or drugs that cost the health insurer more than six hundred dollars ($600) net of rebates for a one-month supply.
(2)In placing specific drugs on specific tiers, or choosing to place a drug on the formulary, the insurer shall take into account the other provisions of this section and this part.
(3)A policy of health insurance may maintain a drug formulary with fewer than four
tiers. A policy of health insurance shall not maintain a drug formulary with more than four tiers.
(4)This section shall not be construed to limit a health insurer from placing any drug in a lower tier. If a biologic has a therapeutic equivalent, consistent with state law, it may be placed on a tier other than tier four.
(h)
(i)
(j)