Legislation


SB 853 – California

Status: In Process
Year Introduced: 2022
Link: https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220SB853

Prescription drug coverage.
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 a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or health insurer to use utilization review, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law prohibits a health care service plan contract that covers prescription drug benefits or a specified health insurance policy from limiting or excluding coverage for a drug on the basis that the drug is prescribed for a use that is different from the use for which it was approved by the federal Food and Drug Administration if specified conditions are met. Existing law also prohibits a health care service plan that covers prescription drug benefits from limiting or excluding coverage for a drug that was previously approved for coverage if an enrollee continues to be prescribed that drug, as specified.

This bill would expand the above-described prohibitions to prohibit limiting or excluding coverage of a dose of a drug. The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2023, that covers prescription drug benefits to provide coverage for a drug or dose of a drug prescribed by a health care provider during utilization review and any appeals. The bill would prohibit a plan or insurer from seeking reimbursement for that coverage if the final utilization review decision is to deny coverage for the prescription drug or dosage.


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