1367.24
. (a) Every health care service plan that provides
prescription drug benefits shall maintain an expeditious process by
which prescribing providers may obtain authorization for a medically
necessary nonformulary prescription drug. On or before July 1, 1999,
every health care service plan that provides prescription drug
benefits shall file with the department a description of its process,
including timelines, for responding to authorization requests for
nonformulary drugs. Any changes to this process shall be filed with
the department pursuant to Section 1352. Each plan shall provide a
written description of its most current process, including timelines,
to its prescribing providers. For purposes of this section, a
prescribing provider shall include a provider authorized to write a
prescription, pursuant to subdivision (a) of Section 4040 of the
Business and Professions Code, to treat a medical condition of an
enrollee.
(b) Any plan that disapproves a request made pursuant to
subdivision (a) by a prescribing provider to obtain authorization for
a nonformulary drug shall provide the reasons for the disapproval in
a notice provided to the enrollee. The notice shall indicate that
the enrollee may file a grievance with the plan if the enrollee
objects to the disapproval, including any alternative drug or
treatment offered by the plan. The notice shall comply with
subdivision (b) of Section 1368.02. Any health plan that is required
to maintain an external exception request review process pursuant to
subdivision (k) shall indicate in the notice required under this
subdivision that the enrollee may file a grievance seeking an
external exception request review.
(c) The process described in subdivision (a) by which prescribing
providers may obtain authorization for medically necessary
nonformulary drugs shall not apply to a nonformulary drug that has
been prescribed for an enrollee in conformance with the provisions of
Section 1367.22.
(d) The process described in subdivision (a) by which enrollees
may obtain medically necessary nonformulary drugs, including
specified timelines for responding to prescribing provider
authorization requests, shall be described in evidence of coverage
and disclosure forms, as required by subdivision (a) of Section 1363,
issued on or after July 1, 1999.
(e) Every health care service plan that provides prescription drug
benefits shall maintain, as part of its books and records under
Section 1381, all of the following information, which shall be made
available to the director upon request:
(1) The complete drug formulary or formularies of the plan, if the
plan maintains a formulary, including a list of the prescription
drugs on the formulary of the plan by major therapeutic category with
an indication of whether any drugs are preferred over other drugs.
(2) Records developed by the pharmacy and therapeutic committee of
the plan, or by others responsible for developing, modifying, and
overseeing formularies, including medical groups, individual practice
associations, and contracting pharmaceutical benefit management
companies, used to guide the drugs prescribed for the enrollees of
the plan, that fully describe the reasoning behind formulary
decisions.
(3) Any plan arrangements with prescribing providers, medical
groups, individual practice associations, pharmacists, contracting
pharmaceutical benefit management companies, or other entities that
are associated with activities of the plan to encourage formulary
compliance or otherwise manage prescription drug benefits.
(f) If a plan provides prescription drug benefits, the department
shall, as part of its periodic onsite medical survey of each plan
undertaken pursuant to Section 1380, review the performance of the
plan in providing those benefits, including, but not limited to, a
review of the procedures and information maintained pursuant to this
section, and describe the performance of the plan as part of its
report issued pursuant to Section 1380.
(g) The director shall not publicly disclose any information
reviewed pursuant to this section that is determined by the director
to be confidential pursuant to state law.
(h) For purposes of this section, "authorization" means approval
by the health care service plan to provide payment for the
prescription drug.
(i) Nonformulary prescription drugs shall include any drug for
which an enrollee's copayment or out-of-pocket costs are different
than the copayment for a formulary prescription drug, except as
otherwise provided by law or regulation or in cases in which the drug
has been excluded in the plan contract pursuant to Section 1342.7.
(j) Nothing in this section shall 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 a health care service plan 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.
(k) For any individual, small group, or large health plan
contracts, a health care service plan's process described in
subdivision (a) shall comply with the request for exception and
external exception request review processes described in subdivision
(c) of Section 156.122 of Title 45 of the Code of Federal
Regulations. This subdivision shall not apply to Medi-Cal managed
care health care service plan contracts as described in subdivision
(l).
(l) "Medi-Cal managed care health care service plan contract"
means any entity that enters into a contract with the State
Department of Health Care Services pursuant to Chapter 7 (commencing
with Section 14000), Chapter 8 (commencing with Section 14200), or
Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9
of the Welfare and Institutions Code.
(m) Nothing in this section shall be construed to affect an
enrollee's or subscriber's eligibility to submit a grievance to the
department for review under Section 1368 or to apply to the
department for an independent medical review under Section 1370.4, or
Article 5.55 (commencing with Section 1374.30) of this chapter.