This bill would require the California State Board of Pharmacy to license and regulate pharmacy benefit managers that manage the prescription drug coverage provided by a health care service plan or health insurer, except as specified. The bill would set forth various duties of pharmacy benefit managers, including requirements to file a report with the board. The bill would prohibit a pharmacy benefit manager from, among other things, contracting after January 1, 2024, to prohibit or restrict a pharmacy or pharmacist from disclosing to an enrollee or insured health care information that the pharmacy or pharmacist considers appropriate.

Existing law, the Medical Practice Act, establishes the Medical Board of California within the Department of Consumer Affairs and sets forth its powers and duties relating to the licensure and regulation of the practice of medicine by physicians and surgeons. Existing law generally prohibits the practice of medicine without a physician’s and surgeon’s certificate issued by the board.
Existing law authorizes a health care provider to deliver health care via telehealth to a patient pursuant to specified protocols and conditions. Existing law defines “telehealth” as the delivery of health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient’s health care, and that telehealth includes synchronous interactions and asynchronous store and forward transfers.
Under this bill, the David Hall Act, a person licensed as a physician and surgeon in another state, as specified, would be authorized to deliver health care via telehealth to an eligible patient who, among other requirements, has an immediately life-threatening disease or condition, as specified.

Medi-Cal: diabetes management. This bill would add continuous glucose monitors and related supplies required for use with those monitors as a covered benefit under the Medi-Cal program, subject to utilization controls based on clinical practice guidelines, as specified. The bill would authorize the department to require a manufacturer of a continuous glucose monitor to enter into a rebate agreement with the department. The bill would limit its implementation to the extent that any necessary federal approvals are obtained and federal financial participation is not otherwise jeopardized. The bill would make related findings and declarations.

Emergency ground medical transportation. This bill would delete that direct reimbursement requirement and would require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. The bill would prohibit a noncontracting ground ambulance provider from billing or sending to collections a higher amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. The bill would require a plan or insurer to reimburse for ground ambulance services at the authorized rate for the specific exclusive operating area, unless it reaches another agreement with the noncontracting ground ambulance provider. Because a willful violation of the bill’s requirements relative to a health care service plan would be a crime, the bill would impose a state-mandated local program.

Prescription drugs.
Existing law, until January 1, 2024, prohibits the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription from exceeding $250 for a supply of up to 30 days, except as specified. Existing law, until January 1, 2024, requires a nongrandfathered individual or small group plan contract or policy to use specified definitions for each tier of a drug formulary.
This bill would delete the January 1, 2024, repeal date of those provisions, thus making them operative indefinitely. Because extension of the bill’s requirements relative to health care service plans would extend the existence of a crime, the bill would impose a state-mandated local program.

Health care coverage: cancer treatment. Existing law prohibits, until January 1, 2024, an individual or group health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2015, that provides coverage for prescribed, orally administered anticancer medications used to kill or slow the growth of cancerous cells from requiring an enrollee or insured to pay a total amount of copayments and coinsurance that exceeds $250 for an individual prescription of up to a 30-day supply of a prescribed orally administered anticancer medication, as specified.
This bill would extend the duration of that prohibition indefinitely. By indefinitely extending the operation of the prohibition, and thus indefinitely extending the applicability of a crime for a willful violation by a health care service plan, the bill would impose a state-mandated local program.

Health care coverage: biosimilar drugs. This bill would specify that a plan, insurer, or utilization review organization is also not prohibited from requiring an enrollee or insured to try a biosimilar before providing coverage for the equivalent branded prescription drug.

Prescription drug pricing. This bill would prohibit a pharmacy benefit manager from discriminating against a covered entity or its pharmacy in connection with dispensing a drug subject to federal pricing requirements or preventing a covered entity from retaining the benefit of discounted pricing for those drugs.

Pelvic floor physical therapy coverage. This bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2024, to provide coverage for pelvic floor physical therapy after pregnancy. Because a willful violation of the bill’s requirements relative to health care service plans would be a crime, the bill would impose a state-mandated local program.

Covered California: expansion.
This bill would declare the intent of the Legislature to enact legislation to expand Covered California access to all Californians regardless of immigration status.