Section 1367.22 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.22
. (a) A health care service plan contract, issued, amended,
or renewed on or after July 1, 1999, that covers prescription drug
benefits shall not limit or exclude coverage for a drug for an
enrollee if the drug previously had been approved for coverage by the
plan for a medical condition of the enrollee and the plan's
prescribing provider continues to prescribe the drug for the medical
condition, provided that the drug is appropriately prescribed and is
considered safe and effective for treating the enrollee's medical
condition. Nothing in this section shall preclude the prescribing
provider from prescribing another drug covered by the plan that is
medically appropriate for the enrollee, nor shall anything in this
section be construed to prohibit generic drug substitutions as
authorized by Section 4073 of the Business and Professions Code. For
purposes of this section, a prescribing provider shall include a
provider authorized to write a prescription, pursuant to subdivision
(a) of Section 4059 of the Business and Professions Code, to treat a
medical condition of an enrollee.
(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) This section shall not be construed to restrict or impair the
application of any other provision of this chapter, including, but
not limited to, Section 1367, which includes among its requirements
that plans furnish services in a manner providing continuity of care
and demonstrate that medical decisions are rendered by qualified
medical providers unhindered by fiscal and administrative management.
(d) This section does not prohibit a health care service plan from
charging a subscriber or enrollee a copayment or a deductible for
prescription drug benefits or from setting forth, by contract,
limitations on maximum coverage of prescription drug benefits,
provided that the copayments, deductibles, or limitations are
reported to, and held unobjectionable by, the director and set forth
to the subscriber or enrollee pursuant to the disclosure provisions
of Section 1363.