Prescription Drugs: Existing law prohibits the formulary or formularies for outpatient prescription drugs maintained by a health care service plan or health insurer from discouraging the enrollment of individuals with health conditions and from reducing the generosity of the benefit for enrollees or insureds with a particular condition. Existing law, until January 1, 2020, provides that the copayment, coinsurance, or any other form of cost sharing for a covered outpatient prescription drug for an individual prescription shall not exceed $250 for a supply of up to 30 days, except as specified. Existing law, until January 1, 2020, 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 extend those provisions indefinitely. The bill would prohibit a drug formulary maintained by a health care service plan or health insurer from containing more than 4 tiers, and would permit a biologic with a therapeutic equivalent to be placed on a tier other than tier 4, as specified. The bill would require a prescription drug benefit to provide that an enrollee or an insured is not required to pay more than the retail price for a prescription drug if a pharmacy’s retail price is less than the applicable copayment or coinsurance amount, and the payment rendered by an enrollee or insured would constitute the applicable cost sharing, as specified.