Health care coverage: antisteering.

All references to health care providers, clinics, infusion centers, and pharmacies are now limited to 'in-network' entities. Protections no longer apply when an out-of-network provider determines a medication should be administered in-office or dispensed by a different pharmacy.

Several provisions now require that the medication be 'covered' and services be 'contracted and covered' before protections apply, adding additional conditions that limit when the anti-discrimination provisions trigger.

The clinical standard for when a provider can override plan direction changed from 'clinically appropriate' (or 'in the best interest of the enrollee clinically appropriate') to 'medically necessary,' which is a higher and more restrictive threshold.

New provision requires health care providers, physician's offices, clinics, or infusion centers to obtain consent from the enrollee or insured and disclose a good faith estimate of the applicable cost-sharing amount before supplying or administering an injected or infused medication if the manner or location of administration differs from what the plan or PBM directed.

Removed the prohibition on conditioning, denying, restricting, or reducing payment to a participating provider for an injected or infused medication when all medical necessity criteria are met solely because the provider obtained the drugs from a non-participating pharmacy. This eliminated a key protection for providers sourcing medications from out-of-network pharmacies.

The reimbursement protection was narrowed from prohibiting any lesser reimbursement amount to only prohibiting reimbursement 'at a lesser than the contracted rate,' meaning it now only applies where a specific contracted rate exists rather than protecting against any payment disparity.

New definitions added for 'dispensing' (tied to Business and Professions Code Section 4170), 'medically necessary' (cross-referencing existing statutory definitions), 'pharmacy benefit manager,' and 'physician's office, clinic, or infusion center' (explicitly excluding outpatient facilities of general acute care hospitals).

In multiple provisions (subsections 1, 2, and the oral medication provision in both Section 1367.48 and Section 10123.1934), the standard for when a health care provider can direct administration or dispensing was changed from 'in the best interest of the enrollee' to 'in the best interest of the enrollee clinically appropriate.' This adds a clinical appropriateness requirement on top of the existing best-interest standard, making it slightly harder for providers to override plan preferences.

A new subsection (b) was added to both Section 1367.48 (Health and Safety Code) and Section 10123.1934 (Insurance Code) stating that the section does not prohibit or interfere with compliance with federal and state law, including registration with the United States Drug Enforcement Administration as required to dispense controlled substances. This is a savings clause that prevents the antisteering provisions from being interpreted as allowing physicians to dispense controlled substances without proper DEA registration.

The former subsection (b) defining 'pharmacy benefit manager' was renumbered to subsection (c) in both sections to accommodate the newly inserted subsection (b).