Health care coverage: prescription drugs.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Commonly referred to as utilization review, existing law governs the procedures that apply to every health care service plan and health insurer that prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based on medical necessity, requests by providers prior to, retrospectively, or concurrent with, the provision of health care services to enrollees or insureds, as specified. Existing law also imposes various requirements and restrictions on health care service plans and health insurers, including, among other things, a prohibition on health care service plans and health insurers that provide prescription drug benefits from excluding or limiting coverage for a drug on the basis that the drug is prescribed for a use that is different from the use for which the drug has been approved for marketing by the federal Food and Drug Administration. Existing law also requires a health care service plan that provides prescription drug benefits to maintain an expeditious process by which prescribing providers, as described, may obtain authorization for a medically necessary nonformulary prescription drug, according to certain procedures. This bill would require the Department of Managed Health Care and the Department of Insurance to, on or before July 1, 2012, develop a prior authorization form for use by every health care service plan and health insurer that provides prescription drug benefits, except as specified. On and after January 1, 2013, or 6 months after the form is developed, whichever is later, the bill would require every prescribing provider, as defined, when requesting prior authorization for prescription drug benefits, to submit the prior authorization form to the health care service plan or health insurer, and would require those plans and insurers to utilize and accept those prior authorization forms for prescription drug benefits. Except as specified, upon a failure by the plan or insurer to accept the prior authorization form or to respond to a prescribing provider within 2 business days, the bill would deem the prior authorization request as granted. Because a willful violation of the bill's provisions relative to health care service plans would be a crime, the bill would impose a state-mandated local program. The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. This bill would provide that no reimbursement is required by this act for a specified reason.