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<ns0:Id>20250AB__200099INT</ns0:Id>
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<ns0:ActionText>INTRODUCED</ns0:ActionText>
<ns0:ActionDate>2026-02-17</ns0:ActionDate>
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<ns0:SessionYear>2025</ns0:SessionYear>
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<ns0:AuthorText authorType="LEAD_AUTHOR">Introduced by Assembly Member Aguiar-Curry</ns0:AuthorText>
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<ns0:Name>Aguiar-Curry</ns0:Name>
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<ns0:Title> An act to amend Section 1367.22 of the Health and Safety Code, relating to prescription drugs. </ns0:Title>
<ns0:RelatingClause>prescription drugs</ns0:RelatingClause>
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<ns0:Subject>Prescription drugs.</ns0:Subject>
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<html:p> 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’s requirements a crime. Existing law requires specified services and drugs to be covered by the various plans. Existing law prohibits specified health care service plan contracts that cover prescription drug benefits from limiting or excluding coverage for a drug for an enrollee under specified conditions, including if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee. Existing law specifies that these provisions do not preclude the prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee.</html:p>
<html:p>This bill would make
technical, nonsubstantive changes to these provisions. The bill would state the intent of the Legislature to protect patients from mid-year health care service plan formulary changes that disrupt care and restrict access to medically necessary medications. </html:p>
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<ns0:Preamble>The people of the State of California do enact as follows:</ns0:Preamble>
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<ns0:Num>SECTION 1.</ns0:Num>
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<html:p>It is the intent of the Legislature to protect patients from mid-year health care service plan formulary changes that disrupt care and restrict access to medically necessary medications. </html:p>
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<ns0:Num>SEC. 2.</ns0:Num>
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Section 1367.22 of the
<ns0:DocName>Health and Safety Code</ns0:DocName>
is amended to read:
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<ns0:Num>1367.22.</ns0:Num>
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(a)
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A health care service plan contract, issued, amended, or renewed on or after July 1, 1999, that covers prescription drug benefits shall not limit or exclude coverage for a drug for an enrollee if the drug previously had been approved for coverage by the plan for a medical condition of the enrollee and the plan’s prescribing provider continues to prescribe the drug for the medical condition, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. This section does not preclude the
prescribing provider from prescribing another drug covered by the plan that is medically appropriate for the enrollee. This section does not prohibit generic drug substitutions as authorized by Section 4073 of the Business and Professions Code. For purposes of this section, a prescribing provider includes a provider authorized to write a prescription, pursuant to subdivision (a) of Section 4059 of the Business and Professions Code, to treat a medical condition of an enrollee.
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(b)
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This section
does not apply to coverage for any drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the federal Food and Drug Administration. Coverage for different-use drugs is subject to Section 1367.21.
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(c)
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This section does not
restrict or impair the application of any other provision of this chapter, including, but not limited to, Section 1367, which includes among its requirements that plans furnish services in a manner providing continuity of care and demonstrate that medical decisions are rendered by qualified medical providers unhindered by fiscal and administrative management.
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(d)
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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 set forth to the subscriber or enrollee pursuant to the disclosure provisions of Section 1363.
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