Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services, including pharmacy services and drugs. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law sets forth a schedule of benefits covered under the Medi-Cal program, including acupuncture, but only to the extent federal matching funds are provided for acupuncture. To the extent federal financial participation is available, this bill would require the Medi-Cal program to cover up to 24 acupuncture visits per beneficiary per calendar year and would state that additional visits per calendar year may be authorized based on medical necessity. This bill would incorporate additional changes to Section 14132 of the Welfare and Institutions Code proposed by AB 350 and SB 944 to be operative only if this bill and either or both AB 350 and SB 944 are enacted and this bill is enacted last. This bill would make certain provisions operative only if both this bill and SB 944 is enacted and takes effect on or before January 1, 2027.
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 also provides for the regulation of health insurers by the Department of Insurance. Existing law, except as provided and under certain circumstances, prohibits a person who manufactures a prescription drug from offering a discount, repayment, product voucher, or other reduction in an individual's out-of-pocket expenses associated with their health insurance or health care service plan. Existing law generally imposes specified cost sharing limits on covered prescription drugs. This bill would require a health care service plan or health insurer, when calculating an enrollee's or insured's overall contribution to an out-of-pocket maximum or cost sharing requirement under the plan contract or insurance policy, to count any amount paid by the enrollee or insured or on behalf of the enrollee or insured for a covered drug toward the enrollee's or insured's cost sharing, except as provided. The bill would prescribe an administrative penalty for each violation by a health insurer that is enforceable by the Insurance Commissioner after appropriate notice and opportunity for hearing. 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.
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 pharmacy benefit manager contracting with a health care service plan or health insurer to secure a license from the Department of Managed Health Care on or after January 1, 2027, or the date on which the department has established the licensure process, whichever is later. This bill would require the department to maintain a public internet website displaying specified information for each licensed pharmacy benefit manager, including, among other things, the legal name, license number, and license expiration date.
Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services through fee-for-service (FFS) or managed care delivery systems. The Medi-Cal program is in part governed by, and funded pursuant to, federal Medicaid program provisions. Under existing law, pharmacist services are a benefit under the Medi-Cal program, subject to federal approval, as specified. Existing law authorizes the department to provide and administer Medi-Cal pharmacy services under a single statewide FFS delivery system, commonly known as the Medi-Cal Rx program. The department has implemented a transition of Medi-Cal pharmacy services, through Medi-Cal Rx, from managed care to FFS as a result of a 2019 executive order by the Governor. This bill would require the department to issue guidance clarifying Medi-Cal managed care plan obligations to cover pharmacist services, as specified. The bill would require the department to update its model evidence of coverage to explicitly include coverage of pharmacist services. The bill would also require the department to take appropriate corrective action for failure to comply with existing provisions of law relating to Medi-Cal coverage of pharmacist services or the issued guidance. The bill would authorize the department to implement, interpret, or make specific these provisions by means of all-plan letters, plan letters, or other similar instructions, without taking any further regulatory action.
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 generally prohibits a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs that are medically necessary for the prevention of HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy. Under existing law, a health care service plan or health insurer is not required to cover all of the therapeutically equivalent versions of those drugs without prior authorization or step therapy if at least one is covered without prior authorization or step therapy. This bill would instead prohibit a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs, drug devices, or drug products that are medically necessary for the prevention of HIV/AIDS to prior authorization or step therapy. The bill would require, for a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, a non-self-administered antiretroviral drug, drug device, or drug product that is approved by the United States Food and Drug Administration for the prevention of HIV/AIDS to be covered under both the plan or policy's medical benefit and prescription drug benefit, and if obtained under the plan or policy's drug benefit, would require the drug, device, or product to be dispensed and administered by a health care provider acting within the scope of their license. Because a willful violation of these provisions by a health care service plan would be a crime, this 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.
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 or health insurer that provides prescription drug benefits and maintains one or more drug formularies to meet certain criteria for its formularies and the placement of drugs on formularies. This bill would prohibit a health care service plan or health insurer that provides prescription drug benefits and maintains one or more drug formularies from making changes to a formulary during a plan or policy year, except in specified circumstances. If a plan or insurer implements a formulary change requiring an enrollee or insured to change to a different drug in the same drug class during the plan year, the bill would authorize the individual to remain on the previously covered drug for the rest of the plan year if the drug was previously approved for coverage for the individual's medical condition, is appropriately prescribed, and is considered safe and effective for treating that condition, and would require the plan or insurer to notify the individual and their provider no less than 90 days before the change is implemented. The bill would require a plan or insurer, or its pharmacy benefit manager, to report to the appropriate department any changes made to a formulary during a plan or policy year within 30 days of the change being made. The bill would authorize the departments to investigate and take enforcement action against a plan or insurer for noncompliance with the above-described requirements and to impose, after notice and the opportunity for a hearing, administrative penalties, as specified, for a violation of these provisions. The bill would authorize the departments to conduct audits related to these provisions. Because a willful violation of the bill's provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program. Existing law requires a health care service plan that provides prescription drug benefits to maintain an expeditious process by which prescribing providers may obtain authorization for a medically necessary nonformulary prescription drug. This bill would define "expeditious process" for the above-described purpose to require a plan to approve authorization within 72 hours for nonurgent requests, or within 24 hours if exigent circumstances exist, of a request for approval of a drug prescription. If the plan fails to meet those requirements, the bill would authorize an enrollee to request, and would require the plan to provide, 90 days of transitional coverage to the enrollee for the previously covered drug. The bill would require the Department of Managed Health Care to utilize existing data and its existing authority to collect data from plans and annually publish on its internet website and submit to the Legislature an aggregated report on information related to requests for approval of a nonformulary drug as described above. 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.
Existing law requires the California Health and Human Services Agency (CHHSA) to enter into partnerships resulting in the production of generic prescription drugs, including at least one form of insulin made available at production and dispensing costs, if one does not already exist in the market. Existing law additionally authorizes CHHSA to enter into partnerships to increase competition, lower prices, and address supply shortages for generic or brand name drugs to address emerging health concerns. This bill, the Preventive Treatment Health Care Act, would authorize CHHSA to enter into partnerships, if needed and subject to an appropriation, to increase competition, lower prices, and address supply shortages for at least one glucagon-like peptide-1 (GLP-1) antiobesity medication approved by the United States Food and Drug Administration (FDA) . The bill would require CHHSA to establish distribution partners, if needed, and make its best effort to negotiate pricing at or lower than the cost to Medi-Cal beneficiaries in 2025.
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 sets forth specified prior authorization and step therapy limitations for health care service plans and health insurers. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, to require a health care service plan or health insurer to complete prior authorization within 30 days upon initial request, as specified, for a drug approved by the United States Food and Drug Administration (FDA) for the treatment of a rare disease if the drug is prescribed by a specialist with expertise in the condition or disease being treated, the specialist has determined the drug is medically necessary, and the drug is the only FDA-approved treatment for the rare disease. 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.
Existing law provides for the Medi-Cal program, administered by the State Department of Health Care Services and under which health care services are provided to low-income individuals pursuant to a schedule of benefits. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Under existing law, pharmacist services are a benefit under the Medi-Cal program, subject to federal approval, and the rate of reimbursement for pharmacist services is 85% of the fee schedule for physician services, except for medication therapy management (MTM) pharmacist services. Existing law requires the department to implement an MTM reimbursement methodology relating to the dispensing of qualified specialty drugs by an eligible contracting pharmacy, which would be intended to supplement Medi-Cal payments to eligible pharmacies for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories. This bill would additionally require the rate of reimbursement for advanced pharmacist practitioner services to be no less than 85% of the fee schedule for physician services, including MTM pharmacist services. The bill would, subject to, among other things, federal approval, require advanced pharmacist practitioners to be recognized as health care providers at federally qualified health centers and rural health clinics for reimbursement purposes under the Medi-Cal program. The bill would require the department to implement an MTM reimbursement methodology relating to the use of drugs to ensure that Medi-Cal payments are only made to eligible advanced pharmacist practitioners or pharmacies, including those operating at federally qualified health centers or rural health clinics, for MTM pharmacist services provided in conjunction with certain specialty drug therapy categories. 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 or disability insurer that offers coverage for pharmacist services to pay or reimburse the cost of the service performed by a pharmacist at an in-network pharmacy or a pharmacist at an out-of-network pharmacy if the insurer has an out-of-network pharmacy benefit. Existing law authorizes this payment or reimbursement when specified conditions are met, including that the coverage otherwise provides reimbursement for identical services performed by other licensed health care providers. This bill would additionally require those health care service plans and disability insurers to pay or reimburse the cost of the service performed by a pharmacist enrolled as a provider with the plan or insurer. The bill would specify for these purposes that a pharmacist includes pharmacists who provide services at a federally qualified health center or a rural health clinic. The bill would authorize payment or reimbursement if the coverage otherwise provides reimbursement for similar services performed by other licensed health care providers, among other requirements. Because a willful violation of the bill's requirements relative to health care service plans 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.
Existing law, the Pharmacy Law, provides for the licensure and regulation of pharmacists by the California State Board of Pharmacy. Existing law authorizes a pharmacist to, among other things, perform certain procedures or functions and furnish specified drugs. Existing law authorizes the refilling of a prescription for a dangerous drug without the authorization of the prescriber if the prescriber is unavailable to authorize the refill and, in the pharmacist's professional judgment, failure to refill the prescription might interrupt the patient's ongoing care and have a significant adverse effect on the patient's well-being. Existing law requires a pharmacist to notify the prescriber, as specified, of any prescription refilled without their authorization. This bill would only require a pharmacist to provide that notification if a prescriber is identified.
