§ 1367.205. — 1367.205. (Amended by Stats. 2015, Ch. 619, Sec. 5.)

California § 1367.205.

• Jurisdiction: California
• Code HSC: Health and Safety Code - HSC
• Div. 2.: DIVISION 2. LICENSING PROVISIONS
• Ch. 2.2.: CHAPTER 2.2. Health Care Service Plans
• Art. 5.: ARTICLE 5. Standards

Text

(a)
In addition to the list required to be provided under Section 1367.20, a health care service plan that provides prescription drug benefits and maintains one or more drug formularies shall do all of the following:
(1)
Post the formulary or formularies for each product offered by the plan on the plan’s Internet Web site in a manner that is accessible and searchable by potential enrollees, enrollees, providers, the general public, the department, and federal agencies as required by federal law or regulations.
(2)
Update the formularies posted pursuant to paragraph (1) with any change to those formularies on a monthly basis.
(3)
No later than six months after the date that a standard formulary template is developed under subdivision (b), use that template to display the formulary or formularies for each product offered by the plan.
(b)
(1)
By January 1, 2017, the department and the Department of Insurance shall jointly, and with input from interested parties from at least one public meeting, develop a standard formulary template for purposes of paragraph (3) of subdivision (a). In developing the template, the department and Department of Insurance shall take into consideration existing requirements for reporting of formulary information established by the federal Centers for Medicare and Medicaid Services. To the extent feasible, in developing the template, the department and the Department of Insurance shall evaluate a way to include on the template, in addition to the information
required to be included under paragraph (2), cost-sharing information for drugs subject to coinsurance.
(2)
The standard formulary template shall include the notification described in subdivision (c) of Section 1363.01, and as applied to a particular formulary for a product offered by a plan, shall do all of the following:
(A)
Include information on cost-sharing tiers and utilization controls, including prior authorization or step therapy requirements, for each drug covered by the product.
(B)
Indicate any drugs on the formulary that are preferred over other drugs on the formulary.
(C)
Include information to educate enrollees about the differences between drugs administered or provided under a health care service plan’s medical benefit and drugs
prescribed under a health care service plan’s prescription drug benefit and about how to obtain coverage information regarding drugs that are not covered under the plan’s prescription drug benefit.
(D)
Include information to educate enrollees that health care service plans that provide prescription drug benefits are required to have a method for enrollees to obtain prescription drugs not listed in the health plan drug formulary if the drugs are deemed medically necessary by a clinician pursuant to Section 1367.24.
(E)
Include information on which medications are covered, including both generic and brand name.
(F)
Include information on what tier of the plan’s drug formulary each medication is in.
(c)
For purposes of this section, “formulary” means the
complete list of drugs preferred for use and eligible for coverage under a health care service plan product and includes the drugs covered under the pharmacy benefit of the product.

Legislative History

Amended by Stats. 2015, Ch. 619, Sec. 5. (AB 339) Effective January 1, 2016.