Section 1367.215 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.215
. (a) Every health care service plan contract that covers
prescription drug benefits shall provide coverage for appropriately
prescribed pain management medications for terminally ill patients
when medically necessary. The plan shall approve or deny the request
by the provider for authorization of coverage for an enrollee who has
been determined to be terminally ill in a timely fashion,
appropriate for the nature of the enrollee's condition, not to exceed
72 hours of the plan's receipt of the information requested by the
plan to make the decision. If the request is denied or if additional
information is required, the plan shall contact the provider within
one working day of the determination, with an explanation of the
reason for the denial or the need for additional information. The
requested treatment shall be deemed authorized as of the expiration
of the applicable timeframe. The provider shall contact the plan
within one business day of proceeding with the deemed authorized
treatment, to do all of the following:
(1) Confirm that the timeframe has expired.
(2) Provide enrollee identification.
(3) Notify the plan of the provider or providers performing the
treatment.
(4) Notify the plan of the facility or location where the
treatment was rendered.
(b) This section does not apply to coverage for any drug that is
prescribed for a use that is different from the use for which that
drug has been approved for marketing by the federal Food and Drug
Administration. Coverage for different-use drugs is subject to
Section 1367.21.
(c) Nothing in this section shall be construed to deny or restrict
in any way the department's authority to ensure plan compliance with
this chapter when a plan provides coverage for prescription drugs.