1342.74.
(a) (1) Notwithstanding Section 1342.71, a health care service plan shall not subject antiretroviral drugs, devices, or products that are either approved by the United States Food and Drug Administration (FDA) or recommended by the federal Centers for Disease Control and Prevention (CDC) for the prevention of AIDS/HIV, HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy, except as provided in paragraph (2).(2) If the FDA has approved
one or more therapeutic equivalents of a drug, device, or product for the prevention of AIDS/HIV, HIV/AIDS, this section does not require a health care service plan to cover all of the therapeutically equivalent versions without prior authorization or step therapy, if at least one therapeutically equivalent version is covered without prior authorization or step therapy and the plan provides coverage for a noncovered therapeutic equivalent antiretroviral drug, device, or product without cost sharing pursuant to an exception request.
(b) Notwithstanding any other law, a health care service plan shall not prohibit, or permit a delegated pharmacy benefit manager to
prohibit, a pharmacy provider from dispensing preexposure prophylaxis or postexposure prophylaxis.
(c) A health care service plan shall not cover preexposure prophylaxis that has been furnished by a pharmacist, as authorized in Section 4052.02 of the Business and Professions Code, in excess of a 60-day supply to a single patient once every two years, unless the pharmacist has been directed otherwise by a prescriber.
(d) This section does not require a health care service plan to cover preexposure prophylaxis or postexposure prophylaxis by a pharmacist at an out-of-network pharmacy, unless the health care service plan has an out-of-network pharmacy benefit.
(e) (1) A nongrandfathered health care service plan
contract shall provide coverage for, and shall not impose any cost-sharing or utilization review requirements for for, antiretroviral drugs, devices, or products that are either approved by the FDA or recommended by the CDC for the prevention of AIDS/HIV, HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis.
(2) A health care service plan contract that is a grandfathered health plan
shall provide coverage, and shall not impose any cost-sharing or utilization review requirements, for antiretroviral drugs, devices, or products that are either approved by the FDA or recommended by the CDC for the prevention of AIDS/HIV, HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis of HIV. prophylaxis.
(f) A In addition to the
coverage a health care service plan provides for prescription drugs that are not self-administered, a health care service plan shall provide coverage under the outpatient prescription drug benefit for antiretroviral drugs, devices, or products that are either approved by the FDA or recommended by the CDC for the prevention of AIDS/HIV, HIV/AIDS, including by supplying participating providers directly with a drug, device, or product that is required by this section and is not self-administered.
(g) (1) This section does not apply to a specialized health care service
plan contract that does not cover an essential health benefit, as defined by Section 1367.005, covers only dental or vision benefits or a Medicare supplement policy. contract.
(2) This section applies to a Medi-Cal managed care plan that contracts with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000) and Chapter 8 (commencing with Section 14200) of Part 3 of Division 9 of the Welfare and Institutions Code.
(3) This section applies regardless of whether or not an antiretroviral drug, device, or product is self-administered.
(h)The department and director may exercise the authority provided by this code and the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340), Chapter 4.5 (commencing with Section 11400), and Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code) to implement and enforce this section. If the department assesses a civil penalty for a violation, any hearing that is requested by the plan shall be conducted by the Office of Administrative Hearings. This subdivision does not impair or restrict the department’s authority pursuant to another provision of this code or the Administrative Procedure Act.
(h) A health care service plan contract that is a high deductible health plan under the definition set forth in Section 223(c)(2) of Title 26 of the United States Code shall comply with the cost-sharing requirements of this section. However, if not applying the minimum annual deductible to an antiretroviral drug, device, or product for postexposure prophylaxis of HIV would conflict with federal requirements for high deductible health plans, the cost-sharing limits shall apply once a contract’s deductible has been satisfied for the plan year.