Health care coverage: prescription drugs: continuity of care.

Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care. Existing law makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Insurance Commissioner. Existing law requires a health care service plan contract or a health insurance policy that provides coverage for outpatient prescription drugs to cover medically necessary prescription drugs, including nonformulary drugs determined to be medically necessary, and authorizes a health care service plan or health insurer to utilize formulary, prior authorization, step therapy, or other reasonable medical management practices in the provision of outpatient prescription drug coverage. Existing law requires a health care service plan health insurer that provides coverage for prescription drugs to utilize a specified uniform prior authorization form or electronic authorization process for prescription drugs that require prior authorization by the plan or health insurer, and requires the plan or health insurer to respond to those prior authorization requests within 72 hours for nonurgent requests and 24 hours if exigent circumstances, as defined, exist. Existing law authorizes a request for an exception to a health care service plan's or health insurer's step therapy process for prescription drugs to be submitted in the same manner as a request for prior authorization for prescription drugs, and requires the plan or health insurer to treat, and respond to, those exception requests in the same manner as a request for prior authorization for prescription drugs. Existing law prohibits a health care service plan contract that covers prescription drug benefits from limiting or excluding 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. This bill would require a health care service plan and health insurer that provides coverage for outpatient prescription drugs to establish an expeditious process, as described, by which enrollees and insureds, enrollees' and insureds' designees, or prescribing providers may request and obtain an exception to any prior authorization process or any other utilization management or medical management practices utilized by the plan or health insurer for medically necessary prescription drugs, and would require a plan or health insurer to grant an exception request under these provisions under specified circumstances to ensure continuity of care for an enrollee or insured who is medically stable and was either previously prescribed the prescription drug within 100 days prior to enrollment or if, within 100 days prior to the exception request, the prescription drug was previously approved for coverage by the plan or insurer for the same medical condition. The bill would require a plan or health insurer to respond to an exception request within 72 hours, or within 24 hours if exigent circumstances exist, following receipt of the exception request. The bill would require a plan or health insurer that denies an exception request to provide the reasons for the denial in a notice provided to the enrollee or insured, as specified. The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2018, that provides coverage for outpatient prescription drugs to provide coverage, without imposing a prior authorization or step therapy process, or any other reasonable utilization management or medical management practices, for a medically necessary nonformulary drug prescribed for an enrollee or insured that was, within the 100-day period immediately preceding the date of the prescription, previously included on a formulary or formularies maintained by the plan or health insurer if specified conditions are satisfied, including that the enrollee's or insured's prescribing provider has determined that prescribing an alternative formulary prescription drug is not medically appropriate for the enrollee or insured or represents a significant health risk to the enrollee or insured. By imposing new requirements on a health care service plan, the willful violation of which is a crime, this 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.