Bill Text – AB-2352 Prescription drug coverage. – California Legislative Information

1367.207.

 (a) A health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:

(1) Upon request of an enrollee or an enrollee’s health care provider, furnish all of the following information regarding a prescription drug to the enrollee or the enrollee’s health care provider:
(A) The enrollee’s eligibility for the prescription drug.
(B) A full formulary list of drugs that are covered under the enrollee’s health care service plan contract.
(C) Cost-sharing information for the drug and other formulary alternatives, including any variance in cost sharing based on the dispensing pharmacy, whether retail or mail order, or the health care provider.
(D) Applicable utilization management requirements for the drug or other formulary alternatives.
(2) Respond in real time to a request made pursuant to paragraph (1) in the same format in which the request was made.
(3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1) in the same format as the request.
(4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time.
(5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code.
(b) A health care service plan shall not do any of the following:
(1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a) based on how the information was requested.
(2) Restrict, prohibit, or otherwise hinder a health care provider from communicating or sharing any of the following:
(A) The information provided pursuant to subdivision (a).
(B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the enrollee’s health care service plan contract.
(C) Information about the cash price of the drug.
(3) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a), which includes charging fees for access to the information, not responding to a request at the time made if a response is reasonably possible, or instituting enrollee consent requirements.
(4) Penalize a health care provider for disclosing the information provided pursuant to subdivision (a).
(5) Penalize a health care provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.
(c) For purposes of this section:
(1) “Cost-sharing information” means the actual out-of-pocket amount an enrollee would be required to pay a dispensing pharmacy or health care provider for a prescription drug under the terms of the enrollee’s health care service plan contract.
(2) “Health care provider” means a person licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.
(3) “Interoperability element” means hardware, software, integrated technologies or related licenses, technical information, privileges, rights, intellectual property, upgrades, or services necessary to provide a response to an enrollee, an enrollee’s health care provider, or a third party acting on behalf of a provider.

10123.204.

 (a) A health insurer that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:

(1) Upon request of an insured or an insured’s health care provider, furnish all of the following information regarding a prescription drug to the insured or the insured’s health care provider:
(A) The insured’s eligibility for the prescription drug.
(B) A full formulary list of drugs that are covered under the insured’s health insurance policy.
(C) Cost-sharing information for the drug and other formulary alternatives, including any variance in cost sharing based on the dispensing pharmacy, whether retail or mail order, or the health care provider.
(D) Applicable utilization management requirements for the drug or other formulary alternatives.
(2) Respond in real time to a request made pursuant to paragraph (1) in the same format in which the request was made.
(3) Allow the use of an interoperability element to provide the information required pursuant to paragraph (1) in the same format as the request.
(4) Ensure that the information provided pursuant to paragraph (1) is current no later than one business day after a change is made and is provided in real time.
(5) Provide the information pursuant to paragraph (1) if the request is made using the drug’s unique billing code and National Drug Code.
(b) A health insurer shall not do any of the following:
(1) Deny or delay a response to a request for the purpose of blocking the release of information pursuant to subdivision (a) based on how the information was requested.
(2) Restrict, prohibit, or otherwise hinder a health care provider from communicating or sharing any of the following:
(A) The information provided pursuant to subdivision (a).
(B) Additional information on any lower cost or clinically appropriate alternative drugs, whether or not they are covered under the insured’s health insurance policy.
(C) Information about the cash price of the drug.
(3) Except as required by law, interfere with, prevent, or materially discourage access, exchange, or use of the information provided pursuant to subdivision (a), which includes charging fees for access to the information, not responding to a request at the time made if a response is reasonably possible, or instituting insured consent requirements.
(4) Penalize a health care provider for disclosing the information provided pursuant to subdivision (a).
(5) Penalize a health care provider for prescribing, administering, or ordering a lower cost or clinically appropriate alternative drug.
(c) For purposes of this section:
(1) “Cost-sharing information” means the actual out-of-pocket amount an insured would be required to pay a dispensing pharmacy or health care provider for a prescription drug under the terms of the insured’s health insurance policy.
(2) “Health care provider” means a person licensed pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code.
(3) “Interoperability element” means hardware, software, integrated technologies or related licenses, technical information, privileges, rights, intellectual property, upgrades, or services necessary to provide a response to an insured, an insured’s health care provider, or a third party acting on behalf of a provider.

source

Add a Comment

Your email address will not be published.