1342.7
. (a) The Legislature finds that in enacting Sections
1367.215, 1367.25, 1367.45, 1367.51, and 1374.72, it did not intend
to limit the department's authority to regulate the provision of
medically necessary prescription drug benefits by a health care
service plan to the extent that the plan provides coverage for those
benefits.
(b) (1) Nothing in this chapter shall preclude a plan from filing
relevant information with the department pursuant to Section 1352 to
seek the approval of a copayment, deductible, limitation, or
exclusion to a plan's prescription drug benefits. If the department
approves an exclusion to a plan's prescription drug benefits, the
exclusion shall not be subject to review through the independent
medical review process pursuant to Section 1374.30 on the grounds of
medical necessity. The department shall retain its role in assessing
whether issues are related to coverage or medical necessity pursuant
to paragraph (2) of subdivision (d) of Section 1374.30.
(2) A plan seeking approval of a copayment or deductible may file
an amendment pursuant to Section 1352.1. A plan seeking approval of a
limitation or exclusion shall file a material modification pursuant
to subdivision (b) of Section 1352.
(c) Nothing in this chapter shall prohibit a plan from charging a
subscriber or enrollee a copayment or deductible for a prescription
drug benefit or from setting forth by contract, a limitation or an
exclusion from, coverage of prescription drug benefits, if the
copayment, deductible, limitation, or exclusion is reported to, and
found unobjectionable by, the director and disclosed to the
subscriber or enrollee pursuant to the provisions of Section 1363.
(d) The department in developing standards for the approval of a
copayment, deductible, limitation, or exclusion to a plan's
prescription drug benefits, shall consider alternative benefit
designs, including, but not limited to, the following:
(1) Different out-of-pocket costs for consumers, including
copayments and deductibles.
(2) Different limitations, including caps on benefits.
(3) Use of exclusions from coverage of prescription drugs to treat
various conditions, including the effect of the exclusions on the
plan's ability to provide basic health care services, the amount of
subscriber or enrollee premiums, and the amount of out-of-pocket
costs for an enrollee.
(4) Different packages negotiated between purchasers and plans.
(5) Different tiered pharmacy benefits, including the use of
generic prescription drugs.
(6) Current and past practices.
(e) The department shall develop a regulation outlining the
standards to be used in reviewing a plan's request for approval of
its proposed copayment, deductible, limitation, or exclusion on its
prescription drug benefits.
(f) Nothing in subdivision (b) or (c) shall permit a plan to limit
prescription drug benefits provided in a manner that is inconsistent
with Sections 1367.215, 1367.25, 1367.45, 1367.51, and 1374.72.
(g) Nothing in this section shall be construed to require or
authorize a plan that contracts with the State Department of Health
Services to provide services to Medi-Cal beneficiaries or with the
Managed Risk Medical Insurance Board to provide services to enrollees
of the Healthy Families Program to provide coverage for prescription
drugs that are not required pursuant to those programs or contracts,
or to limit or exclude any prescription drugs that are required by
those programs or contracts.
(h) Nothing in this section shall be construed as prohibiting or
otherwise affecting a plan contract that does not cover outpatient
prescription drugs except for coverage for limited classes of
prescription drugs because they are integral to treatments covered as
basic health care services, including, but not limited to,
immunosuppressives, in order to allow for transplants of bodily
organs.
(i) The department shall periodically review its regulations
developed pursuant to this section.
(j) This section shall become operative on January 2, 2003, and
shall only apply to contracts issued, amended, or renewed on or after
that date.