1367.25
. (a) A group health care service plan contract, except for
a specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2000, through
December 31, 2015, inclusive, and an individual health care service
plan contract that is amended, renewed, or delivered on or after
January 1, 2000, through December 31, 2015, inclusive, except for a
specialized health care service plan contract, shall provide coverage
for the following, under general terms and conditions applicable to
all benefits:
(1) A health care service plan contract that provides coverage for
outpatient prescription drug benefits shall include coverage for a
variety of federal Food and Drug Administration (FDA)-approved
prescription contraceptive methods designated by the plan. In the
event the patient's participating provider, acting within his or her
scope of practice, determines that none of the methods designated by
the plan is medically appropriate for the patient's medical or
personal history, the plan shall also provide coverage for another
FDA-approved, medically appropriate prescription contraceptive method
prescribed by the patient's provider.
(2) Benefits for an enrollee under this subdivision shall be the
same for an enrollee's covered spouse and covered nonspouse
dependents.
(b) (1) A health care service plan contract, except for a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following services and contraceptive
methods for women:
(A) Except as provided in subparagraphs (B) and (C) of paragraph
(2), all FDA-approved contraceptive drugs, devices, and other
products for women, including all FDA-approved contraceptive drugs,
devices, and products available over the counter, as prescribed by
the enrollee's provider.
(B) Voluntary sterilization procedures.
(C) Patient education and counseling on contraception.
(D) Followup services related to the drugs, devices, products, and
procedures covered under this subdivision, including, but not
limited to, management of side effects, counseling for continued
adherence, and device insertion and removal.
(2) (A) Except for a grandfathered health plan, a health care
service plan subject to this subdivision shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this subdivision.
Cost sharing shall not be imposed on any Medi-Cal beneficiary.
(B) If the FDA has approved one or more therapeutic equivalents of
a contraceptive drug, device, or product, a health care service plan
is not required to cover all of those therapeutically equivalent
versions in accordance with this subdivision, as long as at least one
is covered without cost sharing in accordance with this subdivision.
(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by the
enrollee's provider, a health care service plan shall provide
coverage, subject to a plan's utilization management procedures, for
the prescribed contraceptive drug, device, or product without cost
sharing. Any request by a contracting provider shall be responded to
by the health care service plan in compliance with the Knox-Keene
Health Care Service Plan Act of 1975, as set forth in this chapter
and, as applicable, with the plan's Medi-Cal managed care contract.
(3) Except as otherwise authorized under this section, a health
care service plan shall not impose any restrictions or delays on the
coverage required under this subdivision.
(4) Benefits for an enrollee under this subdivision shall be the
same for an enrollee's covered spouse and covered nonspouse
dependents.
(5) For purposes of paragraphs (2) and (3) of this subdivision,
"health care service plan" shall include Medi-Cal managed care plans
that contract with the State Department of Health Care Services
pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8
(commencing with Section 14200) of Part 3 of Division 9 of the
Welfare and Institutions Code.
(c) Notwithstanding any other provision of this section, a
religious employer may request a health care service plan contract
without coverage for FDA-approved contraceptive methods that are
contrary to the religious employer's religious tenets. If so
requested, a health care service plan contract shall be provided
without coverage for contraceptive methods.
(1) For purposes of this section, a "religious employer" is an
entity for which each of the following is true:
(A) The inculcation of religious values is the purpose of the
entity.
(B) The entity primarily employs persons who share the religious
tenets of the entity.
(C) The entity serves primarily persons who share the religious
tenets of the entity.
(D) The entity is a nonprofit organization as described in Section
6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as
amended.
(2) Every religious employer that invokes the exemption provided
under this section shall provide written notice to prospective
enrollees prior to enrollment with the plan, listing the
contraceptive health care services the employer refuses to cover for
religious reasons.
(d) This section shall not be construed to exclude coverage for
contraceptive supplies as prescribed by a provider, acting within his
or her scope of practice, for reasons other than contraceptive
purposes, such as decreasing the risk of ovarian cancer or
eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an enrollee.
(e) This section shall not 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 contraceptive drugs,
devices, and products.
(f) This section shall not be construed to require an individual
or group health care service plan contract to cover experimental or
investigational treatments.
(g) For purposes of this section, the following definitions apply:
(1) "Grandfathered health plan" has the meaning set forth in
Section 1251 of PPACA.
(2) "PPACA" means the federal Patient Protection and Affordable
Care Act (Public Law 111-148), as amended by the federal Health Care
and Education Reconciliation Act of 2010 (Public Law 111-152), and
any rules, regulations, or guidance issued thereunder.
(3) With respect to health care service plan contracts issued,
amended, or renewed on or after January 1, 2016, "provider" means an
individual who is certified or licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions Code,
or an initiative act referred to in that division, or Division 2.5
(commencing with Section 1797) of this code.