Amended in Assembly August 1, 2016

Amended in Assembly June 20, 2016

Amended in Senate April 18, 2016

Amended in Senate March 29, 2016

Senate Bill No. 999

Introduced by Senator Pavley

(Principal coauthor: Senator Hertzberg)

(Principal coauthors: Assembly Members Atkins, Gomez, and Gonzalez)

(Coauthors: Senators Allen, Beall, Block, Hall, Hill, Jackson, Leyva, Wieckowski, and Wolk)

(Coauthors: Assembly Members Bonilla, Burke, Campos, Chiu, Dababneh, Dodd, Eggman, Cristina Garcia, Gipson, Irwin, Levine, McCarty, Mark Stone, Weber, and Williams)

February 10, 2016

An act to amend Section 4064.5 of the Business and Professions Code, to amend Section 1367.25 of the Health and Safety Code, begin delete and end delete to amend Section 10123.196 of the Insurance Code, begin insert and to add Section 14000.01 to the Welfare and Institutions Code, end insert relating to contraceptives.

LEGISLATIVE COUNSEL’S DIGEST

SB 999, as amended, Pavley. Health begin delete insurance: end delete begin insert care coverage: end insert contraceptives: annual supply.

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 also provides for the regulation of health insurers by the Department of Insurance. begin insert Existing law also provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services through, among other things, managed care plans licensed under the act that contract with the State Department of Health Care Services. end insert Existing law requires a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2016, to provide coverage for women for all prescribed and FDA-approved female contraceptive drugs, devices, and products, as well as voluntary sterilization procedures, contraceptive education and counseling, and related followup services.

This bill would require a health care service plan or a health insurance policy issued, amended, renewed, or delivered on or after January 1, 2017, to cover up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives when dispensed at one time for an enrollee or insured at one time by a provider, pharmacist, or at a location licensed or authorized to dispense drugs or supplies. The bill would specifically provide that a health care service plan contract or an insurance policy is not required to cover contraceptives provided by an out-of-network provider, pharmacy, or other location, except as authorized by state or federal law or by the plan or insurer’s policies governing out-of-network coverage. The bill would also prohibit a health care service plan or health insurer, in the absence of clinical contraindications, from imposing utilization controls limiting the supply of FDA-approved self-administered hormonal contraceptives that may be furnished by a provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies to an amount that is less than a 12-month supply. begin insert The bill would include Medi-Cal managed plans, as specified, in the definition of a health care service plan for purposes of these provisions, and would require the State Department of Health Care Services to issue all-plan letters or similar instructions to implement these provisions. end insert Because a willful violation of the bill’s requirements by a health care service plan would be a crime, the bill would impose a state-mandated local program.

Existing law authorizes a pharmacist to dispense not more than a 90-day supply of a dangerous drug other than a controlled substance pursuant to a valid prescription that specifies an initial quantity of less than a 90-day supply followed by periodic refills of that amount if the patient has met specified requirements, including having completed an initial 30-day supply of the drug. Existing law prohibits a pharmacist from dispensing a greater supply of a dangerous drug if the prescriber indicates “no change to quantity” on the prescription. Existing law authorizes a pharmacist to furnish self-administered hormonal contraceptives in accordance with standardized procedures or protocols developed and approved by both the board and the Medical Board of California, as specified.

This bill would require a pharmacist to dispense, at a patient’s request, up to a 12-month supply of an FDA-approved self-administered hormonal contraceptive pursuant to a valid prescription that specifies an initial quantity followed by periodic refills. The bill would authorize a pharmacist furnishing an FDA-approved self-administered hormonal contraceptive, pursuant to the authorization described above, to furnish up to a 12-month supply at one time at the patient’s request.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.

The people of the State of California do enact as follows:

SECTION 1.  

(a) The Legislature hereby finds all of the
following:

(1) California has a long history of, and commitment to,
expanding access to services that aim to reduce the risk of
unintended pregnancies and improving reproductive health
outcomes.

(2) California’s Family Planning, Access, Care, and Treatment
(Family PACT) Waiver Program, created in 1999, is viewed
nationally as the “gold standard” of publicly funded programs
providing access to reproductive health care. The program has
long recognized the value and importance of providing women
with a year’s supply of birth control.

(3) The Affordable Care Act (ACA) and subsequent federal
regulations made contraceptive coverage a national policy by
requiring most private health insurance plans to provide coverage
for a broad range of preventive services without cost sharing,
including FDA-approved prescription contraceptives.

(4) Since the passage of the ACA, many states have passed laws
strengthening or expanding this federal contraceptive coverage
requirement. In 2014, California passed the Contraceptive
Coverage Equity Act of 2014, which requires plans to cover all
prescribed FDA-approved contraceptives for women without cost
sharing, and requires plans to cover at least one therapeutic
equivalent of a prescribed contraceptive drug, device, or product.

(5) Numerous studies support what California has determined
for decades in the Family PACT program: dispensing a 12-month
supply of birth control at one time has numerous benefits,
including, but not limited to, reducing a woman’s odds of having
an unintended pregnancy by 30 percent, increasing contraception
continuation rates, and decreasing costs per client to insurers by
reducing the number of pregnancy tests and pregnancies.

(6) Access to contraception is a key element in shaping women’s
health and well-being. Nearly all women have used contraceptives
at some point in their lives, and 62 percent are currently using at
least one method.

(7) Several states have mirrored the year-supply requirement
for contraceptive coverage in their publicly funded family planning
or Medicaid programs, recognizing the health benefits of reducing
barriers to continuous and effective use of contraception. Recently,
Oregon and Washington D.C. have gone further to require private
health care service plans and health insurance policies to also cover
a 12-month supply of contraceptives. With California’s history of
leadership in establishing public policies that increase access to
contraceptives, adopting a similar requirement is a natural
progression of our state’s commitment to reducing unintended
pregnancy.

(b) It is therefore the intent of the Legislature to expand on
California’s existing contraceptive coverage policy by requiring
all health care service plans and health insurance policies, including
both commercial and Medi-Cal managed care plans, to cover a
12-month supply of a prescribed FDA-approved contraceptive,
such as the ring, the patch, and oral contraceptives.

SEC. 2.  

Section 4064.5 of the Business and Professions Code
is amended to read:

4064.5.  

(a) A pharmacist may dispense not more than a 90-day
supply of a dangerous drug other than a controlled substance
pursuant to a valid prescription that specifies an initial quantity of
less than a 90-day supply followed by periodic refills of that
amount if all of the following requirements are satisfied:

(1) The patient has completed an initial 30-day supply of the
dangerous drug.

(2) The total quantity of dosage units dispensed does not exceed
the total quantity of dosage units authorized by the prescriber on
the prescription, including refills.

(3) The prescriber has not specified on the prescription that
dispensing the prescription in an initial amount followed by
periodic refills is medically necessary.

(4) The pharmacist is exercising his or her professional
judgment.

(b) For purposes of this section, if the prescription continues
the same medication as previously dispensed in a 90-day supply,
the initial 30-day supply under paragraph (1) of subdivision (a) is
not required.

(c) A pharmacist dispensing an increased supply of a dangerous
drug pursuant to this section shall notify the prescriber of the
increase in the quantity of dosage units dispensed.

(d) In no case shall a pharmacist dispense a greater supply of a
dangerous drug pursuant to this section if the prescriber personally
indicates, either orally or in his or her own handwriting, “No
change to quantity,” or words of similar meaning. Nothing in this
subdivision shall prohibit a prescriber from checking a box on a
prescription marked “No change to quantity,” provided that the
prescriber personally initials the box or checkmark. To indicate
that an increased supply shall not be dispensed pursuant to this
section for an electronic data transmission prescription as defined
in subdivision (c) of Section 4040, a prescriber may indicate “No
change to quantity,” or words of similar meaning, in the
prescription as transmitted by electronic data, or may check a box
marked on the prescription “No change to quantity.” In either
instance, it shall not be required that the prohibition on an increased
supply be manually initialed by the prescriber.

(e) This section shall not apply to psychotropic medication or
psychotropic drugs as described in subdivision (d) of Section 369.5
of the Welfare and Institutions Code.

(f) Except for the provisions of subdivision (d), this section does
not apply to FDA-approved, self-administered hormonal
contraceptives.

(1) A pharmacist shall dispense, at a patient’s request, up to a
12-month supply of an FDA-approved, self-administered hormonal
contraceptive pursuant to a valid prescription that specifies an
initial quantity followed by periodic refills.

(2) A pharmacist furnishing an FDA-approved self-administered
hormonal contraceptive pursuant to Section 4052.3 under protocols
developed by the Board of Pharmacy may furnish, at the patient’s
request, up to a 12-month supply at one time.

(3) Nothing in this subdivision shall be construed to require a
pharmacist to dispense or furnish a drug if it would result in a
violation of Section 733.

(g) Nothing in this section shall be construed to require a health
care service plan, health insurer, workers’ compensation insurance
plan, pharmacy benefits manager, or any other person or entity,
including, but not limited to, a state program or state employer, to
provide coverage for a dangerous drug in a manner inconsistent
with a beneficiary’s plan benefit.

SEC. 3.  

Section 1367.25 of the Health and Safety Code is
amended to read:

1367.25.  

(a)  A group health care service plan contract, except
for a specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2000, to
December 31, 2015, inclusive, and an individual health care service
plan contract that is amended, renewed, or delivered on or after
January 1, 2000, to December 31, 2015, inclusive, except for a
specialized health care service plan contract, shall provide coverage
for the following, under general terms and conditions applicable
to all benefits:

(1)  A health care service plan contract that provides coverage
for outpatient prescription drug benefits shall include coverage for
a variety of federal Food and Drug Administration (FDA)-approved
prescription contraceptive methods designated by the plan. In the
event the patient’s participating provider, acting within his or her
scope of practice, determines that none of the methods designated
by the plan is medically appropriate for the patient’s medical or
personal history, the plan shall also provide coverage for another
FDA-approved, medically appropriate prescription contraceptive
method prescribed by the patient’s provider.

(2)  Benefits for an enrollee under this subdivision shall be the
same for an enrollee’s covered spouse and covered nonspouse
dependents.

(b) (1) A health care service plan contract, except for a
specialized health care service plan contract, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following services and contraceptive
methods for women:

(A) Except as provided in subparagraphs (B) and (C) of
paragraph (2), all FDA-approved contraceptive drugs, devices,
and other products for women, including all FDA-approved
contraceptive drugs, devices, and products available over the
counter, as prescribed by the enrollee’s provider.

(B) Voluntary sterilization procedures.

(C) Patient education and counseling on contraception.

(D) Followup services related to the drugs, devices, products,
and procedures covered under this subdivision, including, but not
limited to, management of side effects, counseling for continued
adherence, and device insertion and removal.

(2) (A) Except for a grandfathered health plan, a health care
service plan subject to this subdivision shall not impose a
deductible, coinsurance, copayment, or any other cost-sharing
requirement on the coverage provided pursuant to this subdivision.
Cost sharing shall not be imposed on any Medi-Cal beneficiary.

(B) If the FDA has approved one or more therapeutic equivalents
of a contraceptive drug, device, or product, a health care service
plan is not required to cover all of those therapeutically equivalent
versions in accordance with this subdivision, as long as at least
one is covered without cost sharing in accordance with this
subdivision.

(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by
the enrollee’s provider, a health care service plan shall provide
coverage, subject to a plan’s utilization management procedures,
for the prescribed contraceptive drug, device, or product without
cost sharing. Any request by a contracting provider shall be
responded to by the health care service plan in compliance with
the Knox-Keene Health Care Service Plan Act of 1975, as set forth
in this chapter and, as applicable, with the plan’s Medi-Cal
managed care contract.

(3) Except as otherwise authorized under this section, a health
care service plan shall not impose any restrictions or delays on the
coverage required under this subdivision.

(4) Benefits for an enrollee under this subdivision shall be the
same for an enrollee’s covered spouse and covered nonspouse
dependents.

(5) For purposes of paragraphs (2) and (3) of this subdivision,
begin insert and subdivision (d), end insert “health care service plan” shall include
Medi-Cal managed care plans that contract with the State
Department of Health Care Services pursuant to Chapter 7
(commencing with Section 14000) and Chapter 8 (commencing
with Section 14200) of Part 3 of Division 9 of the Welfare and
Institutions Code.

(c) Notwithstanding any other provision of this section, a
religious employer may request a health care service plan contract
without coverage for FDA-approved contraceptive methods that
are contrary to the religious employer’s religious tenets. If so
requested, a health care service plan contract shall be provided
without coverage for contraceptive methods.

(1)  For purposes of this section, a “religious employer” is an
entity for which each of the following is true:

(A)  The inculcation of religious values is the purpose of the
entity.

(B)  The entity primarily employs persons who share the
religious tenets of the entity.

(C)  The entity serves primarily persons who share the religious
tenets of the entity.

(D)  The entity is a nonprofit organization as described in
Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of
1986, as amended.

(2)  Every religious employer that invokes the exemption
provided under this section shall provide written notice to
prospective enrollees prior to enrollment with the plan, listing the
contraceptive health care services the employer refuses to cover
for religious reasons.

(d) (1) Every health care service plan contract that is issued,
amended, renewed, or delivered on or after January 1, 2017, shall
cover up to a 12-month supply of FDA-approved, self-administered
hormonal contraceptives when dispensed or furnished at one time
for an enrollee by a provider, pharmacist, or at a location licensed
or otherwise authorized to dispense drugs or supplies.

(2) Nothing in this subdivision shall be construed to require a
health care service plan contract to cover contraceptives provided
by an out-of-network provider, pharmacy, or location licensed or
otherwise authorized to dispense drugs or supplies, except as may
be otherwise authorized by state or federal law or by the plan’s
policies governing out-of-network coverage.

(3) Nothing in this subdivision shall be construed to require a
provider to prescribe, furnish, or dispense 12 months of
self-administered hormonal contraceptives at one time.

(4) A health care service plan subject to this subdivision, in the
absence of clinical contraindications, shall not impose utilization
controls or other forms of medical management limiting the supply
of FDA-approved self-administered hormonal contraceptives that
may be dispensed or furnished by a provider or pharmacist, or at
a location licensed or otherwise authorized to dispense drugs or
supplies to an amount that is less than a 12-month supply.

(e) This section shall not be construed to exclude coverage for
contraceptive supplies as prescribed by a provider, acting within
his or her scope of practice, for reasons other than contraceptive
purposes, such as decreasing the risk of ovarian cancer or
eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an enrollee.

(f) This section shall not be construed to deny or restrict in any
way the department’s authority to ensure plan compliance with
this chapter when a plan provides coverage for contraceptive drugs,
devices, and products.

(g) This section shall not be construed to require an individual
or group health care service plan contract to cover experimental
or investigational treatments.

(h) For purposes of this section, the following definitions apply:

(1) “Grandfathered health plan” has the meaning set forth in
Section 1251 of PPACA.

(2) “PPACA” means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any rules, regulations, or guidance
issued thereunder.

(3) With respect to health care service plan contracts issued,
amended, or renewed on or after January 1, 2016, “provider” means
an individual who is certified or licensed pursuant to Division 2
(commencing with Section 500) of the Business and Professions
Code, or an initiative act referred to in that division, or Division
2.5 (commencing with Section 1797) of this code.

SEC. 4.  

Section 10123.196 of the Insurance Code is amended
to read:

10123.196.  

(a) An individual or group policy of disability
insurance issued, amended, renewed, or delivered on or after
January 1, 2000, through December 31, 2015, inclusive, that
provides coverage for hospital, medical, or surgical expenses, shall
provide coverage for the following, under the same terms and
conditions as applicable to all benefits:

(1) A disability insurance policy that provides coverage for
outpatient prescription drug benefits shall include coverage for a
variety of federal Food and Drug Administration (FDA)-approved
prescription contraceptive methods, as designated by the insurer.
If an insured’s health care provider determines that none of the
methods designated by the disability insurer is medically
appropriate for the insured’s medical or personal history, the insurer
shall, in the alternative, provide coverage for some other
FDA-approved prescription contraceptive method prescribed by
the patient’s health care provider.

(2) Coverage with respect to an insured under this subdivision
shall be identical for an insured’s covered spouse and covered
nonspouse dependents.

(b) (1) A group or individual policy of disability insurance,
except for a specialized health insurance policy, that is issued,
amended, renewed, or delivered on or after January 1, 2016, shall
provide coverage for all of the following services and contraceptive
methods for women:

(A) Except as provided in subparagraphs (B) and (C) of
paragraph (2), all FDA-approved contraceptive drugs, devices,
and other products for women, including all FDA-approved
contraceptive drugs, devices, and products available over the
counter, as prescribed by the insured’s provider.

(B) Voluntary sterilization procedures.

(C) Patient education and counseling on contraception.

(D) Followup services related to the drugs, devices, products,
and procedures covered under this subdivision, including, but not
limited to, management of side effects, counseling for continued
adherence, and device insertion and removal.

(2) (A) Except for a grandfathered health plan, a disability
insurer subject to this subdivision shall not impose a deductible,
coinsurance, copayment, or any other cost-sharing requirement on
the coverage provided pursuant to this subdivision.

(B) If the FDA has approved one or more therapeutic equivalents
of a contraceptive drug, device, or product, a disability insurer is
not required to cover all of those therapeutically equivalent versions
in accordance with this subdivision, as long as at least one is
covered without cost sharing in accordance with this subdivision.

(C) If a covered therapeutic equivalent of a drug, device, or
product is not available, or is deemed medically inadvisable by
the insured’s provider, a disability insurer shall provide coverage,
subject to an insurer’s utilization management procedures, for the
prescribed contraceptive drug, device, or product without cost
sharing. Any request by a contracting provider shall be responded
to by the disability insurer in compliance with Section 10123.191.

(3) Except as otherwise authorized under this section, an insurer
shall not impose any restrictions or delays on the coverage required
under this subdivision.

(4) Coverage with respect to an insured under this subdivision
shall be identical for an insured’s covered spouse and covered
nonspouse dependents.

(c) This section shall not be construed to deny or restrict in any
way any existing right or benefit provided under law or by contract.

(d) This section shall not be construed to require an individual
or group disability insurance policy to cover experimental or
investigational treatments.

(e) Notwithstanding any other provision of this section, a
religious employer may request a disability insurance policy
without coverage for contraceptive methods that are contrary to
the religious employer’s religious tenets. If so requested, a
disability insurance policy shall be provided without coverage for
contraceptive methods.

(1) For purposes of this section, a “religious employer” is an
entity for which each of the following is true:

(A) The inculcation of religious values is the purpose of the
entity.

(B) The entity primarily employs persons who share the religious
tenets of the entity.

(C) The entity serves primarily persons who share the religious
tenets of the entity.

(D) The entity is a nonprofit organization pursuant to Section
6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code of 1986, as
amended.

(2) Every religious employer that invokes the exemption
provided under this section shall provide written notice to any
prospective employee once an offer of employment has been made,
and prior to that person commencing that employment, listing the
contraceptive health care services the employer refuses to cover
for religious reasons.

(f) (1) A group or individual policy of disability insurance,
except for a specialized health insurance policy, that is issued,
amended, renewed, or delivered on or after January 1, 2017, shall
cover up to a 12-month supply of FDA-approved, self-administered
hormonal contraceptives when dispensed or furnished at one time
for an insured by a provider, pharmacist, or at a location licensed
or otherwise authorized to dispense drugs or supplies.

(2) Nothing in this subdivision shall be construed to require a
policy to cover contraceptives provided by an out-of-network
provider, pharmacy, or location licensed or otherwise authorized
to dispense drugs or supplies, except as may be otherwise
authorized by state or federal law or by the insurer’s policies
governing out-of-network coverage.

(3) Nothing in this subdivision shall be construed to require a
provider to prescribe, furnish, or dispense 12 months of
self-administered hormonal contraceptives at one time.

(4) A health insurer subject to this subdivision, in absence of
clinical contraindications, shall not impose utilization controls or
other forms of medical management limiting the supply of
FDA-approved self-administered hormonal contraceptives that
may be dispensed or furnished by a provider or pharmacist, or at
a location licensed or otherwise authorized to dispense drugs or
supplies to an amount that is less than a 12-month supply.

(g) This section shall not be construed to exclude coverage for
contraceptive supplies as prescribed by a provider, acting within
his or her scope of practice, for reasons other than contraceptive
purposes, such as decreasing the risk of ovarian cancer or
eliminating symptoms of menopause, or for contraception that is
necessary to preserve the life or health of an insured.

(h) This section only applies to disability insurance policies or
contracts that are defined as health benefit plans pursuant to
subdivision (a) of Section 10198.6, except that for accident only,
specified disease, or hospital indemnity coverage, coverage for
benefits under this section applies to the extent that the benefits
are covered under the general terms and conditions that apply to
all other benefits under the policy or contract. This section shall
not be construed as imposing a new benefit mandate on accident
only, specified disease, or hospital indemnity insurance.

(i) For purposes of this section, the following definitions apply:

(1) “Grandfathered health plan” has the meaning set forth in
Section 1251 of PPACA.

(2) “PPACA” means the federal Patient Protection and
Affordable Care Act (Public Law 111-148), as amended by the
federal Health Care and Education Reconciliation Act of 2010
(Public Law 111-152), and any rules, regulations, or guidance
issued thereunder.

(3) With respect to policies of disability insurance issued,
amended, or renewed on or after January 1, 2016, “health care
provider” means an individual who is certified or licensed pursuant
to Division 2 (commencing with Section 500) of the Business and
Professions Code, or an initiative act referred to in that division,
or Division 2.5 (commencing with Section 1797) of the Health
and Safety Code.

begin insert

begin insert SEC. 5. end insert   

end insert

begin insert Section 14000.01 is added to the end insert begin insert Welfare and
Institutions Code end insert begin insert , to read: end insert

begin insert

begin insert 14000.01. end insert   

The department shall issue all-plan letters or similar
instructions to implement subdivision (d) of Section 1367.25 of
the Health and Safety Code.

end insert

begin delete SEC. 5. end delete

begin insert SEC. 6. end insert   

No reimbursement is required by this act pursuant to
Section 6 of Article XIII B of the California Constitution because
the only costs that may be incurred by a local agency or school
district will be incurred because this act creates a new crime or
infraction, eliminates a crime or infraction, or changes the penalty
for a crime or infraction, within the meaning of Section 17556 of
the Government Code, or changes the definition of a crime within
the meaning of Section 6 of Article XIII B of the California
Constitution.