Cost sharing – prescription drugs:
1) Prohibits the drug formularies used by health insurers and health plans from discouraging the enrollment of individuals with health conditions and from reducing the generosity of the benefit for enrollees with a particular condition;
2) For combination antiretroviral drugs for the treatment of AIDS/HIV, health insurers and health plans are required to cover a single-tablet regimen unless the multi- tablet regimen is shown to be equally effective and more likely to result in adherence to a drug regimen;
3) Prohibits more than 50% of approved drugs in the same drug class from being assigned to the two highest tiers of a drug formulary;
4) Requires all drug formularies to include at least one drug in the lower cost tiers if all approved drugs would otherwise be in the highest cost tiers and at least three drugs are available in the drug class;
5) Requires that the drug or drugs assigned to the lower tiers be those drugs that were most often prescribed in the preceding year;
6) Limits cost sharing for a 30-day supply of a prescription drug to $250 (or $500 for a bronze level plan and only once the deductible has been satisfied for a high deductible health plan).
7) Specifies the criteria for formulary tiers that must be used by health insurers and health plans that include a fourth or specialty tier;
The above requirements went into effect on July 1, 2016 for group health plans or insurance policies and go into effect on January 1, 2017 for individual market health plans and health insurance policies, and the above requirements do not apply to Medi-Cal managed care plans;
8) Specifies the timelines and procedures for requesting coverage of a non-formulary drug by a prescriber (this modifies an existing requirement on health plans and creates a new requirement on health insurers);
9) Requires carriers to have a pharmacy and therapeutics committee responsible for developing a health insurer’s or health plan’s drug formulary, with specified requirements; and
10) Requires health insurers and health plans to allow enrollees to access prescription drugs at an in-network retail pharmacy unless the drug is subject to federal restrictions on distribution; Require health insurers and health plans to provide access to drug formularies to the general public and state regulators and require carriers to include information on cost sharing and what tier of a formulary each medication is on.
See Sacramento Business Journal Article.