Section 1342.71 Of Article 1. General From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 1.
1342.71
. (a) The Legislature hereby finds and declares all of the
following:
(1) The federal Patient Protection and Affordable Care Act, its
implementing regulations and guidance, and related state law prohibit
discrimination based on a person's expected length of life, present
or predicted disability, degree of medical dependency, quality of
life, or other health conditions, including benefit designs that have
the effect of discouraging the enrollment of individuals with
significant health needs.
(2) The Legislature intends to build on existing state and federal
law to ensure that health coverage benefit designs do not have an
unreasonable discriminatory impact on chronically ill individuals,
and to ensure affordability of outpatient prescription drugs.
(3) Assignment of all or most prescription medications that treat
a specific medical condition to the highest cost tiers of a formulary
may effectively discourage enrollment by chronically ill
individuals, and may result in lower adherence to a prescription drug
treatment regimen.
(b) A nongrandfathered health care service plan contract that is
offered, amended, or renewed on or after January 1, 2017, shall
comply with this section.
(c) A health care service plan contract that provides coverage for
outpatient prescription drugs shall cover medically necessary
prescription drugs, including nonformulary drugs determined to be
medically necessary consistent with this chapter.
(d) (1) Consistent with federal law and guidance, the formulary or
formularies for outpatient prescription drugs maintained by the
health care service plan shall not discourage the enrollment of
individuals with health conditions and shall not reduce the
generosity of the benefit for enrollees with a particular condition
in a manner that is not based on a clinical indication or reasonable
medical management practices. Section 1342.7 and any regulations
adopted pursuant to that section shall be interpreted in a manner
that is consistent with this section.
(2) For combination antiretroviral drug treatments that are
medically necessary for the treatment 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.
(e) A health care service plan contract shall ensure that the
placement of prescription drugs on formulary tiers is based on
clinically indicated, reasonable medical management practices.
(f) This section shall not be construed to require a health care
service plan to impose cost sharing. This section shall not be
construed to require cost sharing for prescription drugs that state
or federal law otherwise requires to be provided without cost
sharing.
(g) This section does not require or authorize a health care
service plan that contracts with the State Department of Health Care
Services to provide services to Medi-Cal beneficiaries 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) In the provision of outpatient prescription drug coverage, a
health care service plan may utilize formulary, prior authorization,
step therapy, or other reasonable medical management practices
consistent with this chapter.
(i) This section shall not apply to a health care service plan
that contracts with the State Department of Health Care Services.
(j) This section shall become operative on January 1, 2020.