Bill Text: CA AB369 | 2011-2012 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Health care coverage: prescription drugs.

Spectrum: Partisan Bill (Democrat 7-0)

Status: (Vetoed) 2012-09-30 - Consideration of Governor's veto pending. [AB369 Detail]

Download: California-2011-AB369-Amended.html

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BILL NUMBER: AB 369	AMENDED
	BILL TEXT

	AMENDED IN SENATE  MAY 21, 2012

INTRODUCED BY   Assembly Member Huffman
   (Coauthors: Assembly Members  Beall  
Ammiano,   Beall,   Carter,   Chesbro,
 and Feuer)
   (Coauthor: Senator Pavley)

                        FEBRUARY 14, 2011

   An act to add Section 1367.243 to the Health and Safety Code, and
to add Section 10123.192 to the Insurance Code, relating to health
care coverage.



	LEGISLATIVE COUNSEL'S DIGEST


   AB 369, as amended, Huffman. 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, requiring 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. Existing law also requires every health care
service plan that provides prescription drug benefits that maintains
one or more drug formularies to provide to members of the public,
upon request, a copy of the most current list of prescription drugs
on the formulary.
   This bill would impose specified requirements on health care
service plans or health insurers that restrict medications for the
treatment of pain pursuant to step therapy or fail first protocol.
The bill would authorize the duration of any step therapy or fail
first protocol to be determined by the prescribing  physician
  provider, as defined,  and would prohibit a
health care service plan or health insurer from requiring that a
patient try and fail on more than  two   2 
pain medications before allowing the patient access to other pain
medication prescribed by the  physician  
prescribing provider  , as specified.
   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.
   Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.


THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:

  SECTION 1.  Section 1367.243 is added to the Health and Safety
Code, to read:
   1367.243.  (a) Notwithstanding any other provision of law, a
health care service plan that restricts medications for the treatment
of pain pursuant to step therapy or fail first protocol shall be
subject to the requirements of this section.
   (b) The duration of any step therapy or fail first protocol shall
be determined by the prescribing  physician  
provider  .
   (c) The health care service plan shall not require a patient to
try and fail on more than two pain medications before allowing the
patient access to the pain medication, or generically equivalent
drug, prescribed by the  physician   prescribing
provider .
   (d) Once a patient has tried and failed on two pain medications,
prior authorization is no longer required and the  physician
  prescribing provider  may write the prescription
for the appropriate pain medication. A note in the patient's chart
that a patient has tried and failed on the health care service plan's
step therapy or fail first protocol shall suffice as prior
authorization from the plan.
   (e) When the  physician   prescribing
provider  notes on the prescription that the health care service
plan's step therapy or fail first protocols have been met, a
pharmacist may process the prescription without additional
communication with the plan. 
   (f) For purposes of this section, a "prescribing provider" shall
include a provider who is authorized to write a prescription,
pursuant to subdivision (a) of Section 4040 of the Business and
Professions Code, to treat a medical condition of an enrollee. 

   (f) 
    (g)  For the purposes of this section, "generically
equivalent drug" means drug products with the same active chemical
ingredients of the same strength, quantity, and dosage form, and of
the same generic drug name, as determined by the United States
Adopted Names and accepted by the federal Food and Drug
Administration, as those drug products having the same chemical
ingredient. 
   (g) 
    (h)  This section does not prohibit a health care
service plan from charging a subscriber or enrollee a copayment or a
deductible for prescription drug benefits or from setting forth, by
contract, limitations on maximum coverage of prescription drug
benefits, provided that the copayments, deductibles, or limitations
are reported to, and held unobjectionable by, the director and
communicated to the subscriber or enrollee pursuant to the disclosure
provisions of Section 1363. 
   (h) 
    (i)  Nothing in this section shall be construed to
require coverage of prescription drugs not in a plan's drug formulary
or to prohibit generically equivalent drugs or generic drug
substitutions as authorized by Section 4073 of the Business and
Professions Code.
  SEC. 2.  Section 10123.192 is added to the Insurance Code, to read:

   10123.192.  (a) Notwithstanding any other provision of law, a
health insurer that restricts medications for the treatment of pain
pursuant to step therapy or fail first protocol shall be subject to
the requirements of this section.
   (b) The duration of any step therapy or fail first protocol shall
be determined by the prescribing  physician  
provider  .
   (c) The health insurer shall not require a patient to try and fail
on more than two pain medications before allowing the patient access
to the pain medication, or generically equivalent drug, prescribed
by the  physician   prescribing provider  .

   (d) Once a patient has tried and failed on two pain medications,
prior authorization is no longer required and the  physician
  prescribing provider  may write the prescription
for the appropriate pain medication. A note in the patient's chart
that a patient has tried and failed on the health insurer's step
therapy or fail first protocol shall suffice as prior authorization
from the insurer.
   (e) When the  physician   prescribing
provider  notes on the prescription that the health insurer's
step therapy or fail first protocols have been met, a pharmacist may
process the prescription without additional communication with the
insurer. 
   (f) For purposes of this section, a "prescribing provider" shall
include a provider who is authorized to write a prescription,
pursuant to subdivision (a) of Section 4040 of the Business and
Professions Code, to treat a medical condition of an insured. 

   (f) 
    (g)  For the purposes of this section, "generically
equivalent drug" means drug products with the same active chemical
ingredients of the same strength, quantity, and dosage form, and of
the same generic drug name, as determined by the United States
Adopted Names and accepted by the federal Food and Drug
Administration, as those drug products having the same chemical
ingredient. 
   (g) 
    (h)  This section does not prohibit a health insurer
from charging an insured or policyholder a copayment or a deductible
for prescription drug benefits or from setting forth, by contract,
limitations on maximum coverage of prescription drug benefits,
provided that the copayments, deductibles, or limitations are
reported to, and held unobjectionable by, the commissioner and
communicated to the insured or policyholder pursuant to the
disclosure provisions of Section 10603. 
   (h) 
    (i)  Nothing in this section shall be construed to
require coverage of prescription drugs not in an insurer's drug
formulary or to prohibit generically equivalent drugs or generic drug
substitutions as authorized by Section 4073 of the Business and
Professions Code.
  SEC. 3.  No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of the
Government Code, or changes the definition of a crime within the
meaning of Section 6 of Article XIII B of the California
Constitution.