Health care coverage: prescriptions.

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, and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law requires a health care service plan or health insurer that covers outpatient prescription drug benefits to provide coverage for specified prescription drugs, and requires cost sharing for outpatient prescription drugs to be reasonable so as to allow access to medically necessary outpatient prescription drugs. This bill would limit the amount a health care service plan or health insurer may require an enrollee or insured to pay at the point of sale for a covered prescription to the lesser of the applicable cost-sharing amount or the retail price. The bill would prohibit a health care service plan or health insurer from requiring a pharmacy to charge or collect a cost-sharing amount from an enrollee or insured that exceeds the total retail price for the prescription drug, and would provide that the payment rendered by an enrollee or insured would constitute the applicable cost sharing, as specified. The bill would require a pharmacy to inform a customer whether the retail price for a covered prescription is lower than the applicable cost-sharing amount, unless the pharmacy automatically charges the customer the lower price. If the customer pays the retail price, the bill would require the pharmacy to submit the claim to the health care service plan or health insurer in the same manner as if the customer had purchased the prescription drug by paying the cost-sharing amount when submitted by the network pharmacy. The bill would make a contract provision that is inconsistent with these provisions void and unenforceable. 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.