Section 1367.205 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.205
. (a) In addition to the list required to be provided under
Section 1367.20, a health care service plan that provides
prescription drug benefits and maintains one or more drug formularies
shall do all of the following:
(1) Post the formulary or formularies for each product offered by
the plan on the plan's Internet Web site in a manner that is
accessible and searchable by potential enrollees, enrollees,
providers, the general public, the department, and federal agencies
as required by federal law or regulations.
(2) Update the formularies posted pursuant to paragraph (1) with
any change to those formularies on a monthly basis.
(3) No later than six months after the date that a standard
formulary template is developed under subdivision (b), use that
template to display the formulary or formularies for each product
offered by the plan.
(b) (1) By January 1, 2017, the department and the Department of
Insurance shall jointly, and with input from interested parties from
at least one public meeting, develop a standard formulary template
for purposes of paragraph (3) of subdivision (a). In developing the
template, the department and Department of Insurance shall take into
consideration existing requirements for reporting of formulary
information established by the federal Centers for Medicare and
Medicaid Services. To the extent feasible, in developing the
template, the department and the Department of Insurance shall
evaluate a way to include on the template, in addition to the
information required to be included under paragraph (2), cost-sharing
information for drugs subject to coinsurance.
(2) The standard formulary template shall include the notification
described in subdivision (c) of Section 1363.01, and as applied to a
particular formulary for a product offered by a plan, shall do all
of the following:
(A) Include information on cost-sharing tiers and utilization
controls, including prior authorization or step therapy requirements,
for each drug covered by the product.
(B) Indicate any drugs on the formulary that are preferred over
other drugs on the formulary.
(C) Include information to educate enrollees about the differences
between drugs administered or provided under a health care service
plan's medical benefit and drugs prescribed under a health care
service plan's prescription drug benefit and about how to obtain
coverage information regarding drugs that are not covered under the
plan's prescription drug benefit.
(D) Include information to educate enrollees that health care
service plans that provide prescription drug benefits are required to
have a method for enrollees to obtain prescription drugs not listed
in the health plan drug formulary if the drugs are deemed medically
necessary by a clinician pursuant to Section 1367.24.
(E) Include information on which medications are covered,
including both generic and brand name.
(F) Include information on what tier of the plan's drug formulary
each medication is in.
(c) For purposes of this section, "formulary" means the complete
list of drugs preferred for use and eligible for coverage under a
health care service plan product and includes the drugs covered under
the pharmacy benefit of the product.