Bill Text: CA SB950 | 2025-2026 | Regular Session | Amended
Bill Title: Health care coverage: dementia.
Sponsorship: Moderate Partisan Bill (Democrat 5-1)
Status: (Engrossed) 2026-07-01 - From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 16. Noes 0.) (June 30). [SB950 Detail]
Download: California-2025-SB950-Amended.html
|
Amended
IN
Senate
April 20, 2026 |
CALIFORNIA LEGISLATURE—
2025–2026 REGULAR SESSION
Senate Bill
No. 950
| Introduced by Senator Weber Pierson (Coauthors: Senators Grayson, Richardson, and Smallwood-Cuevas) (Coauthors: Assembly Members Davies and Schiavo) |
February 02, 2026 |
An act to add Section 1373.15 to the Health and Safety Code, and to add Section 10123.175 to the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 950, as amended, Weber Pierson.
Health care coverage: dementia.
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’s requirements a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law prohibits specified health care service plan contracts and disability insurance policies from excluding persons covered by the plan from receiving benefits if they are diagnosed as having any significant destruction of brain tissue with resultant loss of brain function, including Alzheimer’s disease.
This bill would require a health care service plan contract or health insurance policy that is issued, amended, or renewed on or after January 1, 2027, to include coverage for all medically necessary
treatments or medications, as determined by a health care provider, approved by the United States Food and Drug Administration (FDA) for the treatment of Alzheimer’s disease or other related dementia. Under the bill, contracts and policies would not be required to cover drugs or treatments that are pharmaceutically equivalent drug products if the FDA approves more than one. On and after January 1, 2027, the bill would prohibit a health care service plan or health insurer from imposing step therapy protocols as a prerequisite to authorizing that coverage, except as provided. The bill would require a health care service plan or health insurer that, as a medical benefit, covers nonself-administered treatments approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory to also include those nonself-administered treatments as an outpatient prescription drug benefit.
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.
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 1373.15 is added to the Health and Safety Code, to read:1373.15.
(a) (1) A health care service plan contract that is issued, amended, or renewed on or after January 1, 2027, shall include coverage for all medically necessary treatments or medications, as determined by a health care provider, approved by the United States Food and Drug Administration (FDA) for the treatment of Alzheimer’s disease or other related dementia. Medically necessary treatments or medications include, but are not limited to, those that reduce clinical decline.(2) Medically
necessary treatments or medications covered pursuant to paragraph (1) include those administered through a medical benefit, an outpatient prescription drug benefit to the extent the health care service plan contract covers outpatient prescription drugs, or both.
(3) Coverage for all medically necessary treatment or medications pursuant to paragraph (1) does not require a health care service plan contract to cover drugs or treatments that are pharmaceutically equivalent drug products if the FDA approves more than one medication or treatment that are pharmaceutically equivalent drug products, unless otherwise required by law.
(b) (1) On and after January 1, 2027, a health care service plan shall not impose step therapy protocols as a prerequisite to authorizing coverage of medically necessary treatments or medications
approved by the FDA for the treatment of Alzheimer’s disease, except as provided in paragraph (3). For purposes of this section, “step therapy protocol” means a process that specifies the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed.
(2) For purposes of this subdivision, step therapy is prohibited for both self-administered drugs and physician-administered drugs, except as provided in paragraph (3).
(3) If the FDA has approved one or more types of treatment for Alzheimer’s disease or other medical conditions affecting memory, this section does not require a health care service plan to cover all types of treatment for Alzheimer’s disease or other medical conditions affecting
memory without step therapy, if at least one antiamyloid therapy is covered without step therapy.
(c) This section does not prohibit a health care service plan from applying utilization management, including prior authorization, to determine the medical necessity for treatment of Alzheimer’s or other medical conditions affecting memory if appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by the plan contract.
(d) Coverage criteria for FDA-approved treatments described in this section shall not be more restrictive than the FDA-approved indications for those treatments.
(e)Notwithstanding paragraph (3) of subdivision (b), a health care service plan that, as a medical benefit, covers nonself-administered treatments approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory shall also include those
nonself-administered treatments approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory as an outpatient prescription drug benefit.
(f)
(e) For purposes of this section, a health care service plan shall maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary treatment approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory,
memory shall be considered an exigent circumstance, consistent with the requirements of this article. Section 1367.241.
(g)
(f) This section does not apply to the following:
(1) A specialized health care service plan contract that covers only dental or vision benefits or a Medicare supplement contract.
(2) A Medi-Cal managed care plan contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.
SEC. 2.
Section 10123.175 is added to the Insurance Code, to read:10123.175.
(a) (1) A health insurance policy that is issued, amended, or renewed on or after January 1, 2027, shall include coverage for all medically necessary treatments or medications, as determined by a health care provider, approved by the United States Food and Drug Administration (FDA) for the treatment of Alzheimer’s disease or other related dementia. Medically necessary treatments or medications include, but are not limited to, those that reduce clinical decline.(2) Medically
necessary treatments or medications covered pursuant to paragraph (1) include those administered through a medical benefit, an outpatient prescription drug benefit to the extent the health insurance policy covers outpatient prescription drugs, or both.
(3) Coverage for all medically necessary treatment or medications pursuant to paragraph (1) does not require a health insurance policy to cover drugs or treatments that are pharmaceutically equivalent drug products if the FDA approves more than one medication or treatment that are pharmaceutically equivalent drug products, unless otherwise required by law.
(b) (1) On and after January 1, 2027, a health insurer shall not impose step therapy protocols as a prerequisite to authorizing coverage of medically necessary treatments or medications approved by the FDA
for the treatment of Alzheimer’s disease, except as provided in paragraph (3). For purposes of this section, “step therapy protocol” means a process that specifies the sequence in which different prescription drugs for a given medical condition and medically appropriate for a particular patient are prescribed.
(2) For purposes of this subdivision, step therapy is prohibited for both self-administered drugs and physician-administered drugs, except as provided in paragraph (3).
(3) If the FDA has approved one or more types of treatment for Alzheimer’s disease or other medical conditions affecting memory, this section does not require a health insurer to cover all types of treatment for Alzheimer’s disease or other medical conditions affecting memory without step therapy, if at least one
antiamyloid therapy is covered without step therapy.
(c) This section does not prohibit a health insurer from applying utilization management, including prior authorization, to determine the medical necessity for treatment of Alzheimer’s or other medical conditions affecting memory if appropriateness and medical necessity determinations are made in the same manner as those determinations are made for the treatment of any other illness, condition, or disorder covered by the plan contract.
(d) Coverage criteria for FDA-approved treatments described in this section shall not be more restrictive than the FDA-approved indications for those treatments.
(e)Notwithstanding paragraph (3) of subdivision (b), a health insurer that, as a medical benefit, covers nonself-administered treatments approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory shall also include those nonself- administered treatments approved by the FDA for
the treatment of Alzheimer’s disease or other medical conditions affecting memory as an outpatient prescription drug benefit.
(f)
(e) For purposes of this section, a health insurer shall maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary treatment approved by the FDA for the treatment of Alzheimer’s disease or other medical conditions affecting memory,
memory shall be considered an exigent circumstance,
consistent with the requirements of this article. Section 10123.191.
(g)
(f) This section does not apply to vision-only, dental-only, accident-only, specified disease, hospital indemnity, or Medicare supplement insurance policies.
