Prescription drug cost sharing.
(1) 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 under authority of the Director of 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 under the authority of the Insurance Commissioner. Existing law limits the maximum amount an enrollee or insured may be required to pay at the point of sale for a covered prescription drug to the lesser of the applicable cost-sharing amount or the retail price.

This bill would require an enrollee’s or insured’s defined cost sharing for each prescription drug to be calculated at the point of sale based on a price that is reduced by an amount equal to 90% of all rebates received, or to be received, in connection with the dispensing or administration of the drug. The bill would require a health care service plan or health insurer to, among other things, pass through to each enrollee or insured at the point of sale a good faith estimate of their decrease in cost sharing. The bill would require a health care service plan or health insurer to calculate an enrollee’s or insured’s defined cost sharing and provide that information to the dispensing pharmacy, as specified. The bill would require a health care service plan or health insurer to disclose information, as specified, sufficient to show compliance with these provisions to the director or commissioner.

The bill would prohibit a health care service plan, health insurer, or a plan’s or insurer’s agents from publishing or otherwise revealing information regarding the actual amount of rebates the health care service plan or health insurer receives on a product-specific, manufacturer-specific, or pharmacy-specific basis. The bill would make a violation of its provisions not a crime under the act. The bill would authorize the director or commissioner to assess a civil penalty for each violation of these provisions, as specified. The bill would make those provisions inoperative on January 1, 2025.

The bill would require the department and the commissioner, on or before March 1 each year, to provide a report on the impact of those provisions on drug prices and health care premium rates, as specified.

The bill would repeal those provisions January 1, 2026.

(2) Existing law requires a health care service plan or health insurer that files certain rate information to report to the appropriate department specified cost information regarding covered prescription drugs, including generic drugs, brand name drugs, and specialty drugs, dispensed as provided.

This bill, until January 1, 2025, would require a health care service plan or health insurer to report additional information on the above-described point of sale provision. Because a willful violation of these provisions by a health care service plan would be a crime, the bill would impose a state-mandated local program.