BILL ANALYSIS Ó
AB 339
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Date of Hearing: April 28, 2015
ASSEMBLY COMMITTEE ON HEALTH
Rob Bonta, Chair
AB 339
(Gordon) - As Amended April 7, 2015
SUBJECT: Health care coverage: outpatient prescription drugs.
SUMMARY: Expands coverage for outpatient prescriptions drugs by
a health care service plan or insurer and places specified
restrictions on copayments, coinsurance, and other cost sharing.
Specifically, this bill:
1)Requires a plan or policy that covers prescription drugs to
cover all medically necessary prescription drugs, including
those for which there is no other therapeutic equivalent.
2)Requires that copayments, coinsurance, and other cost sharing
for outpatient prescription drugs be reasonable.
3)Requires the plan or insurer to demonstrate to the regulatory
agency that the proposed cost sharing will not discourage
medication adherence. Requires the plan or insurer to
demonstrate that the formulary does not discourage the
enrollment of individuals with health conditions and does not
reduce the generosity of the benefit for enrollees with
specific conditions.
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4)Requires the plan or policy to cover of single-tablet and
extended release regimens if they are clinically as, or more,
effective than a multi-tablet drug regimen.
5)Prohibits a plan or policy from placing most or all of the
drugs to treat a single condition on the highest cost tier of
a formulary, unless there is a therapeutic equivalent drug
available in a lower cost tier.
6)Requires a plan or policy formulary to be the same or
comparable in the individual market as in the group market.
7)Limits, for plans and policies in both individual and group
market, the copayment, coinsurance, or other cost sharing for
an individual outpatient prescription drug to 1/24 of the
annual out-of-pocket limit for a 30 day supply.
8)Requires plans and insurers to use formulary tiers defined as:
a) Tier one consists of preferred generic drugs or
comparably priced preferred branded drugs;
b) Tier two consists of nonpreferred generic drugs,
preferred branded drugs, and any other drugs recommend by
the pharmaceutical and therapeutics committee (P&T) based
on safety and efficacy and not solely based on the cost of
the drug;
c) Tier three consists of nonpreferred brand name drugs
that are recommended by the P&T based on safety and
efficacy and not solely based on the cost of the drug; and,
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d) Tier four consist of biologics, as defined, or drugs
that cost more than the Medicare Part D threshold, if
recommended by the P&T based on safety and efficacy.
Prohibits placement in this tier based solely on the cost
of the drug.
EXISTING LAW:
1)Regulates health plans through the Department of Managed
Health Care and health insurance policies through the
Department of Insurance.
2)Mandates the 10 federally required Essential Health Benefits
(EHBs) and establishes Kaiser Small Group health plan as
California's EHB benchmark plan.
3)Requires, on or after January 1, 2015, for non-grandfathered
health plan contracts or health insurance policies in the
individual and small group markets, to provide for a limit on
annual out-of-pocket expenses for all covered benefits that
meet the definition of EHB, including out-of-network emergency
care, as specified. For large group, requires a
non-grandfathered health plan or health insurer to provide for
a limit on annual out-of-pocket expenses for covered benefits,
including out-of-network emergency care, as specified.
Requires this limit to only apply to EHBs that are covered
under the plan or policy to the extent that this provision
does not conflict with federal law or guidance on
out-of-pocket maximums.
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4)Requires the maximum out-of-pocket limit to apply to any
copayment, coinsurance, deductible and any other form of cost
sharing for all covered benefits that meet the definition of
EHB.
5)Limits the total maximum out-of-pocket limit for all EHBs to
the dollar amounts in effect under the Internal Revenue
Service, as specified, as adjusted by the Patient Protection
and Affordable Care Act (ACA), as specified.
6)Limits, for an individual or group health care service plan
contract or health insurance policy issued, amended, or
renewed on or after January 1, 2015, that provides coverage
for prescribed, orally administered anticancer medications
used to kill or slow the growth of cancerous cells, the total
amount of copayments and coinsurance an enrollee or insured is
required to pay for orally administered anticancer medications
to $200 for an individual prescription of up to a 30-day
supply.
7)Establishes Covered California as California's health benefit
exchange where individuals and small employers can purchase
standardized health insurance from selectively contracted
qualified health plans based on bronze, silver, gold and
platinum actuarial level categories.
FISCAL EFFECT: This bill has not been analyzed by a fiscal
committee.
COMMENTS:
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1)PURPOSE OF THIS BILL. According to the author, the goal of
this bill is to implement and improve upon concepts from
federal guidance and Covered California in order to ensure
that Californians are better able to afford their prescription
drugs and that the anti-discrimination provisions of the ACA
remain intact. The author asserts that this bill is needed to
address the devastating financial effects of high
out-of-pocket prescription expenses. High cost drugs are
often on the highest cost tier of a drug formulary with
coinsurance of up to 20%. As a result, a patient may exhaust
their annual out-of-pocket limit of $6,600 with a single
prescription in the first month. Too many patients are forced
to choose between paying for their life-saving drugs and
paying for housing, child care, or food. When patients cannot
afford their medication, research shows that they skip doses,
they cut pills in half, and they don't fill their
prescription. The author argues that this bill benefits
Californians with chronic and serious health conditions by
implementing concepts from federal guidance, improving upon
them around the anti-discrimination provisions of the ACA, and
by increasing Californians' access to essential prescription
drugs
2)BACKGROUND. According to the California Health Benefits
Review Program (CHBRP), prescription drug benefits are a
specific type of covered benefit usually subject to cost
sharing as part of the medical benefit or a separate
outpatient prescription drug benefit. The separate drug
benefit designs can be characterized by the number of tiers
(up to four) into which drug classes and specific medications
are assigned. Each tier has a distinct cost sharing level
and/or form; the lower tiers are less costly to both the
enrollee and to the health plan or insurer. Some payers use a
four-tier system which includes life-style drugs and specialty
drugs in the fourth tier; typically these are the most costly
drugs. The four-tier design frequently results in greater
enrollee out-of-pocket expenses. CHBRP notes that there is no
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standard industry definition of specialty prescription drugs,
but it is generally recognized by many payers as prescription
drugs with an average minimum monthly cost of $1,150. Other
criteria may include prescription drugs that treat a rare
disease, require special handling, or have a limited
distribution network. Most of the conditions targeted by
these specialty drugs tend to be chronic and progressive in
nature and can impact quality of life, along with morbidity
and mortality. Examples include growth hormone disorders,
rheumatoid arthritis, asthma, multiple sclerosis, hepatitis C,
hemophilia, cancer, and lupus.
In 2013, the annual California HealthCare Foundation employer
benefits survey found that 66% of covered California workers
had a three- or four-tier cost sharing formula for
prescription drugs. Nationally, 82% of covered workers were
subject to three- or four-tier formulas.
3)Cost Sharing for Outpatient Prescription Drugs in California.
Payment for covered health insurance benefits is shared
between the payer (e.g., health plan/insurer or employer) and
the enrollee. Specifically, the patient cost-share is the
portion that enrollees are responsible for paying
out-of-pocket directly to the provider for the health care
service or treatment (including prescription drugs) covered by
the plan or policy. Noncovered services or treatments are
always paid in full by the enrollee. Common cost-sharing
mechanisms include copayments, coinsurance, and/or deductibles
(but do not include premium payments), collectively
out-of-pocket expenses. Health plans and insurers use many
different combinations of cost-sharing mechanisms to help
assure medically necessary treatment and control costs.
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The following steps describe a common interaction of a set of
cost-sharing mechanisms. CHBRP notes that there are numerous
cost-sharing combinations, and this example will not apply to
all situations.
a) Deductibles. Deductibles are a fixed dollar amount
(lump sum for one or more services) an enrollee is required
to pay out-of-pocket within a given time period (e.g., a
year) before the health plan or insurer begins to pay, in
part or in whole, for covered health care services. A plan
or policy can have more than one deductible, for example, a
general deductible that applies to a specified set of
covered medical benefits and another deductible that
applies to prescription drugs or hospital admissions.
Deductibles can range from $200 for an outpatient pharmacy
benefit to $2,500 or more for a family medical benefit.
Not all plans and policies have deductibles.
b) Copayments and/or Coinsurance. Copayments and
coinsurance are activated after the deductible has been
met, if a plan/policy has a deductible. Copayment is a
form of cost sharing in which an enrollee pays a
predetermined, flat dollar amount out-of-pocket at the time
of receiving a health care service or when paying for a
prescription, such as a $5 copayment for a generic
prescription drug. Copayments can vary across covered
benefits, and a plan or policy may not require any
copayments or may only require copayments for some covered
benefits. Coinsurance is the percentage of covered health
care costs for which an enrollee is responsible, such as
25% of a hospitalization charge. As with copayments,
coinsurance percentages can vary across covered benefits,
and a plan or policy may not require any coinsurance or may
only require coinsurance for some covered benefits. It is
not unusual for a prescription drug benefit plan to use
copayments and coinsurance. For example, many times,
generics are subject to a copayment, whereas specialty
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drugs are subject to a coinsurance.
c) Annual out-of-pocket maximums. Annual out-of-pocket
maximums are limits on the enrollee's cost-sharing
obligations in a 1-year period. Health care services that
are not covered by the health plan or insurer would not be
included in the maximum; enrollees are responsible for the
full charges associated with noncovered services.
4)SINGLE AND MULTIPLE TABLET REGIMENS. Single-tablet regimens
typically refer to fixed-dose pills that combine multiple
drugs from the same or different drug classes into a single
tablet<1>. This is in contrast to multiple tablet regimens
where prescribed medications to treat a condition are taken as
separate tablets<2>. This is primarily seen in chronic
conditions requiring multiple pills each day. The advantages
of the single-tablet combination drug regimen are that taking
one single daily pill simplifies treatment, cuts down on
errors, and leads to better adherence with the treatment
regimen.
5)PHARMACY AND THERAPEUTICS COMMITTEE. The P&T committee is a
medical staff advisory group of a hospital, health or
---------------------------
<1> U.S. Food and Drug Administration (FDA). Combination
Products. Silver Spring, Maryland: FDA; 2011. Accessed March
12, 2015.
http://www.fda.gov/CombinationProducts/AboutCombinationProducts/u
cm118332.htm.
<2> Sax PE, Meyers JL, Mugavero M, Davis KL (2012) Adherence to
Antiretroviral Treatment and Correlation with Risk of
Hospitalization among Commercially Insured HIV Patients in the
United States. PLoS ONE 7(2): e31591.
doi:10.1371/journal.pone.0031591
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insurance plan, or pharmacy benefit manager (PBM) that decides
which drugs will appear on that entity's drug formulary. The
P&T committee is responsible for managing the formulary
system. It is composed of actively practicing physicians,
other prescribers, pharmacists, nurses, administrators,
quality improvement managers, and other health care
professionals and staff who participate in the medication-use
process. The P&T committee serves in an evaluative,
educational, and advisory capacity to the medical staff and
organizational administration in all matters pertaining to the
use of medications. The P&T committee's primary role is make
clinical decisions based on scientific evidence, such as
peer-reviewed medical literature, and standards of practice,
such as well-established clinical practice guidelines.
Depending on the size of the entity, the P&T committee may
weigh the costs and benefits of each drug and decide which
ones provide the most efficacy per dollar.
6)RECENT FEDERAL REGULATIONS ON DRUG BENEFIT DESIGN. On
November 26, 2014, the Federal Government released the HHS
Notice of Benefit and Payment Parameters for 2016 proposed
rule and reiterated the prohibition on discrimination found in
Section 1302(b(4) of the Affordable Care Act and 45 CFR
156.125. In this notice, Centers for Medicare and Medicaid
Services (CMS) cautions issuers - meaning plans and insurers -
to avoid discouraging enrollment of individuals with chronic
health needs and cites different examples of practices that
effectively discriminate against or discourage enrollment by
individuals who have chronic medical conditions. The final
rule, released on February 27, 2015, reaffirmed the guidance
provided in the proposed rule and cautioned health plans and
insurers that the examples cited appear discriminatory in
their application when looking at the totality of the
circumstances, and may be prohibited. The examples cited are
as follows:
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a) Placing Most or All Drugs that Treat a Specific
Condition on the Highest Cost Tiers. The federal guidance
states that placing most or all drugs that treat a specific
condition on the highest cost tiers in effect discriminates
against or discourages enrollment based on health
condition. A number of health plans and insurers have
placed on the fourth tier of the drug formulary a number of
high cost or "specialty" drugs that meet the criteria
enunciated by CMS as "most or all drugs that treat a
specific condition."
b) Refusal to Cover a Single-Tablet Drug Regimen or
Extended-Release Product. The federal rule also cites as
discriminatory the "refusal to cover a single-tablet drug
regimen or extended-release product that is customarily
prescribed and is just as effective as a multi-tablet drug
regimen, absent an appropriate reason for such refusal."
Without a valid, nondiscriminatory reason for not covering
these drug products, "such a plan design effectively
discriminates against, or discourages enrollment by,
individuals who would benefit from such innovative
therapeutic options."
Some products in the California individual market in 2014
failed to cover the HIV/AIDS drug cocktail, which is a
single-tablet drug regimen that is the standard of care for
persons with HIV/AIDS. Advocates in the HIV/AIDS community
indicate that some individuals have stayed on the AIDS Drug
Assistance Program rather than transitioning to
comprehensive coverage in the individual market precisely
because some health plans appear not to cover the HIV/AIDS
drug cocktail. Exclusion of the HIV/AIDS drug cocktail, a
customarily prescribed product that is just as effective as
other regimens, is pointed to as a benefit design that
effectively discriminates against, or discourages
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enrollment by, persons with HIV/AIDS, making it a
discriminatory benefit design. In a report entitled
"Disease Matters: Comparing Prescription Drug Benefits in
Covered California Plans," the California Health Foundation
found that some consumers with chronic diseases or those
who rely on specialty drugs, including those with HIV/AIDS,
may have faced access and affordability challenges in 2014.
c) Formulary Design Must be Based on Clinical Guidelines
and/or Medical Evidence. In its final rule, CMS reiterates
the requirement that in designing formularies, "Issuers are
expected to impose limitations and exclusions based on
clinical guidelines and medical evidence, and are expected
to use reasonable medical management." As previously
stated, health plans and insurers have put a number of
drugs to treat a specific condition, commonly known as
specialty drugs, on the highest cost tiers of the formulary
based solely on the cost of the drug to the health plan
without any regard for clinical guidelines, medical
evidence, or reasonable medical management.
The final rule also requires health plans to use a P&T
committee to develop drug formularies and specifies standards
for this process. The standards require P&T committees to
"make clinical decisions based on scientific evidence, such as
peer-reviewed medical literature, and standards of practice,
such as well-established clinical practice guidelines." In
addition, P&T committees are required to ensure that a
formulary drug list does not "discourage enrollment by any
group of enrollees."
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Health plans and insurers that base the fourth/specialty tier
of a formulary purely on the cost of the drug to the health
plan, without regard for whether the drug requires special
handling, special monitoring or specialty administration, is
problematic for consumers with serious or chronic health
conditions. Such practices has led in some instances to all
HIV/AIDS drugs being placed on a specialty tier: the average
cost of these drugs is $1,000 - $1,500 per monthly
prescription and the cost threshold most commonly used to
place drugs on the fourth/specialty tier is $600. This
formulary design has a discriminatory impact for those living
with HIV/AIDS. Similarly, those with multiple sclerosis who
are commonly treated with two drugs, one a biologic and
another (a DMARD), will find that their drugs are on a
specialty tier. These drugs can cost as much as $5,000 or
$10,000 for a monthly prescription. Consumers with multiple
sclerosis describe going to the pharmacy never knowing how
much they will pay in any given month.
7)Recent Covered California Actions on Specialty Drugs. On
March 5, 2015, Covered California adopted guidelines for
formulary design in health plans sold through the Exchange.
The new guidelines:
a) Standardize definitions of formulary tiers as:
i) Tier 1: most generic drugs and low cost preferred
brands;
ii) Tier 2: nonpreferred generic drugs, preferred
branded drugs, drugs recommended by the plan's P&T
committee based on safety, efficacy, and cost;
iii) Tier 3: non-preferred branded drugs, drugs
recommended by the plan's P&T committee based on safety,
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efficacy, and cost, drugs that generally have a preferred
or less costly therapeutic alternative at a lower cost;
amd,
iv) Tier 4: biologics, drugs with specialty handling
limitations, drugs that are self-administered and require
training and clinical management, or cost more than $600.
b) State that if three or more treatment options are
available for a chronic condition that would otherwise be
in Tier 4 / specialty tier, then at least one drug for that
condition must be in a lower tier.
c) Covered California is considering limiting consumers'
cost-sharing for drugs on Tier 4 / specialty tier. Covered
California is gathering information on premium impacts of
implementing cost-sharing caps for these drugs for
consideration at the next board meeting in May 2015.
8)SUPPORT. Health Access California, sponsor of this bill,
states that this bill is would prevent discrimination against
consumers with health conditions by setting standards for cost
sharing of prescription drugs. This bill would put in place
consumer protections that are consistent with federal law and
regulations to offer important consumer protections to
Californians with chronic conditions. Biocom states that this
bill sets realistic limits on out-of-pocket expenses for
patients, while maintaining a plan's ability to direct
patients to therapeutically equivalent lower cost drugs. This
bill will help insure that patients have access to medications
deemed by their physician to be the best course of treatment
for the specific patient. The California Academy of Physician
Assistants write that if patients have consistent, affordable
access to their medications they are more likely to adhere to
the medications regiment prescribed by their provider.
Medication adherence is essential to improving health and
outcomes for people with chronic conditions. Pricing
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specialty medications far out of reach, due to excessively
high co-insurance, often results in an inability of the
patient to adhere to their treatment plan, further
jeopardizing their health.
9)OPPOSITION. California Association of Health Plans states
that this bill does nothing to control the high underlying
cost of pharmaceuticals, nor does it do anything to encourage
the makers of drugs to be more efficient and lower costs.
Opponents argue that this bill would increase costs for all
consumers because health plans will be forced to absorb almost
all of the cost of expensive drugs and then spread that cost
across all enrollees. California Association of Health
Underwriters states that this bill's real world impact, if
enacted, will be to ensure that costs for specialty drugs are
shifted from out of pocket costs to premiums increases for all
health care consumers. The Pharmaceutical Care Management
Association states that annual out-of-pocket expense caps were
just implemented in 2013, and it is therefore too early to be
changing the metrics by which caps are determined. They state
that administration of this proposal would be burdensome
because current computer and benefit management systems are
not configured to adjudicate monthly maximums and partial
transactions. Opponents of this bill state that restrictions
on formulary design are burdensome and unnecessary, and will
not be consistent with Covered California's broader policies
emphasizing cost-savings and access. Kaiser Permanente, with
an oppose unless amended position, states the need to wait
until Covered California's final action is determined before
having a clear sense of amendments that would be requested in
this bill.
10)RELATED LEGISLATION. AB 463 (Chiu) requires a pharmaceutical
manufacturer that sells a prescription drug in California that
has a wholesale acquisition cost of $10,000 or more per year
to file an annual report with the Office of Statewide Health
Planning and Development regarding the pricing of prescription
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drugs. AB 463 bill is pending in Assembly Health Committee.
11)PREVIOUS LEGISLATION.
a) AB 1917 (Gordon) of 2014 would have established limits
on the copayment, coinsurance, or any other form of cost
sharing for a covered outpatient prescription drug for an
individual prescription of 1/12 (equivalent to $529 for
2014) of the annual out-of-pocket limit as specified under
the ACA.
b) AB 219 (Perea), Chapter 661, Statutes of 2013, limits
the total amount of copayments and coinsurance an enrollee
or insured is required to pay for orally administered
anticancer medications to $200 for an individual
prescription of up to a 30-day supply. Governor Brown wrote
in a message approving AB 219 that this policy is not
without the potential for unintended consequences and that
placing a price cap on a specific class of drugs for a
specific class of diseases might not be a policy for the
ages. A sunset on the bill allows for examination of
intended and unintended consequences before embracing the
policy long term.
c) SB 639 (Ed Hernández), Chapter 316, Statutes of 2013,
places in California law provisions of the ACA relating to
out-of-pocket limits on health plan enrollee and insured
cost-sharing, health plan and insurer actuarial value
coverage levels and catastrophic coverage requirements, and
requirements on health insurers with regard to coverage for
out-of-network emergency services. Applies health plan
enrollee and insured out-of-pocket limits to specialized
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products that offer EHBs. Allows carriers in the small
group market to establish an index rate no more frequently
than each calendar quarter.
d) AB 1000 (Perea) of 2011 would have required a health
plan contract or health insurance policy that provides
coverage for prescription drugs and cancer chemotherapy
treatment to limit enrollee out-of-pocket costs for
prescribed, orally administered anti-cancer medications. AB
1000 was vetoed by Governor Brown, stating that the bill
doesn't distinguish between health plans and insurers who
make these drugs available at a reasonable cost and those
who do not.
e) SB 961 (Wright, 2010) which was virtually identical to
AB 1000, was vetoed by Governor Schwarzenegger, who stated
in his veto message that the bill would have added costs to
increasingly expensive health insurance premiums and it was
unnecessary in light of federal health reform.
12)POLICY COMMENTS.
a) This bill will be reviewed by CHBRP. The Committee
submitted a request to CHBRP, housed within the University
of California, to review this bill and perform an analysis
of the clinical efficacy, cost-effectiveness, and public
health impact of its provisions. CHBRP is established in
state statute to assess legislation that proposes or
repeals a mandated benefit or service for public health,
medical, and financial impact. Committee rules provide
that the Committee may not hear such bills until CHBRP's
assessment is received and has been reviewed by committee
staff. Since this bill does not propose a new mandated
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benefit, but rather would require plans and insurers to
limit out-of-pocket expenses and cover different
formulations of already covered medication, this bill may
be heard by the Committee without the CHBRP analysis.
CHBRP provided background information for this analysis,
and will provide a full analysis on May 19, 2015. The
CHBRP analysis will provide valuable information on the
fiscal impacts of tier design, tier restrictions, and
capping monthly out-of-pocket prescription expenditures.
b) Covered California decision is pending. Covered
California is considering action on the issue of benefit
design as it relates to drug formulary tiers and
cost-sharing. Covered California is expected to make a
final decision for the 2016 plan year at the May 2015 board
meeting. As such, the provisions of this bill that put a
cap on cost-sharing may be preliminary.
c) Tiering based on cost. In Medicare, any drug that costs
more than $600 is placed on the specialty tier.
Clarifications in the recent final CMS ruling seems to
indicate that placing expensive drugs in a high tier is not
itself a discriminatory practice if no other discriminatory
factors are present, but that plans should be careful to
ensure that the overall result for patients is not
discriminatory. Covered California recently adopted
guidelines for formulary design in health plans sold
through the exchange and decided that drugs placed on the
fourth/specialty tier can be based solely on cost.
Consumer advocates opposed Covered California's definition
and requested that the definition of specialty drug be
based both on the need for special handling, monitoring or
administration as well as the cost to the health plan and
that it not be based solely on cost to the plan. The
committee may wish to consider whether the statutory
requirements of the fourth tier should be consistent with,
or different from, the Covered California definition.
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13)SUGGESTED AMENDMENTS.
a) In the provisions of this bill relating to multi-tablet
vs single tablet regimens, there is inconsistency in
whether a covered drug may be "as effective" or should be
"more effective" than another. Proving that a multi-tablet
formula is more effective may be an unreasonable standard.
The author may wish to clarify this language.
b) Depending on the size of the plan, insurer, or Pharmacy
Benefit Manager, P&T committees sometimes serve purely in a
clinical role to provide drug recommendations while in
other entities they also consider cost as part of
recommendations. The author may wish to amend the bill to
clarify that the P&T committee is not required to consider
cost as a factor.
c) The bill requires that plans or insurers demonstrate to
the satisfaction of the regulator that they meet specific
requirements. Plans and insurers regularly demonstrate to
the regulator, but the phrase "to the satisfaction of the
director / commissioner" seems to be redundant and should
be removed to avoid confusion.
d) Recent Covered California guidelines require plans to
place one drug in a lower cost tier if three or more
treatment options are available to treat the same
condition. This bill makes the same requirement when there
are two or more treatment options for the same condition.
The author may wish to amend this bill to three or more,
consistent with the Covered California guidelines.
REGISTERED SUPPORT / OPPOSITION:
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Support
Health Access (sponsor)
AIDS Project Los Angeles
American Federation of State, County, and Municipal Employees,
AFL-CIO
Association of Northern California Oncologists
Berkeley Free Clinic
Biocom
California Academy of Physician Assistants
California Black Health Network
California Chronic Care Coalition
California Communities United Institute
California Healthcare Institute
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California LGBT Health and Human Services Network
California Nurses Association
California Pan-Ethnic Health Network
California Teachers Association
CALPIRG
Community Clinic Association
Comprehensive Opiate Recovery Experience Medical Clinic
Consumers Union
Epilepsy California
Hemophilia Council of California
Los Angeles LGBT Center
National Association of Social Workers, California Chapter
National Multiple Sclerosis Society - CA
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National Psoriasis Foundation
National Stroke Association
Project Inform
San Francisco AIDS Foundation
San Luis Obispo County AIDS Support Network
SLO Hep C Project
Stroke Advocacy Network
Western Center on Law and Poverty
Opposition
America's Health Insurance Plans
Blue Shield of California
CalChamber
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California Association of Health Plans
California Association of Health Underwriters
California Association Joint Powers Authorities
CSAC Excess Insurance Authority
CVS Health
Express Scripts
Health Net
Kaiser Permanente (unless amended)
Pharmaceutical Care Management Association
Simi Valley Chamber of Commerce
Analysis Prepared by:Dharia McGrew / HEALTH / (916) 319-2097
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