BILL NUMBER: AB 974	INTRODUCED
	BILL TEXT


INTRODUCED BY  Assembly Member Gallegos
   (Principal coauthor: Senator Leslie)

                        FEBRUARY 27, 1997

   An act to add Section 1367.22 to the Health and Safety Code,
relating to health care service plans.


	LEGISLATIVE COUNSEL'S DIGEST


   AB 974, as introduced, Gallegos.  Health care service plans:
prescription drug benefits.
   Under existing law, the Knox-Keene Health Care Service Plan Act of
1975, health care service plans are regulated by the Department of
Corporations. Willful violation of the act is a crime.
   Existing law requires health care service plans to furnish
services in a manner providing continuity of care and to be able to
demonstrate to the department that medical decisions are rendered by
qualified medical providers, unhindered by fiscal and administrative
management.
   This bill would require, for health care service plan contracts
covering prescription drug benefits issued, amended, or renewed on or
after January 1, 1998, that drug therapy regimens, as described, be
included within the services for which continuity of care is
required, that the choice of drug therapy regimen be included in the
meaning of medical decisions, and that coverage for a drug not be
limited or excluded for a patient if the drug had previously been
approved for the patient as part of an ongoing drug therapy regimen.

   The bill would also require every health care service plan that
covers prescription drug benefits to comply with certain requirements
regarding notice to enrollees of the use of and content of the plan'
s formulary, and would require the plan to provide access to a
toll-free telephone number for information about whether specific
drugs are on the plan's formulary.
   By changing the definition of a crime, the bill would impose a
state-mandated local program.
  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.  Section 1367.22 is added to the Health and Safety Code,
to read:
   1367.22.  (a) All of the following shall apply to a health care
service plan contract, issued, amended, or renewed on or after
January 1, 1998, that covers prescription drug benefits:
   (1) Drug therapy regimens shall be included within the services
for which continuity of care is required by subdivision (d) of
Section 1367.
   (2) The choice of drug therapy regimen shall be included within
the meaning of medical decisions as used in subdivision (g) of
Section 1367.
   (3) Coverage for a drug shall not be limited or excluded for a
patient if the drug had previously been approved for coverage by the
plan for the patient as part of an ongoing drug therapy regimen.
   (b) For purposes of this section, "drug therapy regimen" shall
include a single medication or combination of medications, prescribed
by a person authorized to write a prescription pursuant to Section
4059 of the Business and Professions Code, to treat a medical
condition of a patient.
   (c) Every health care service plan that covers prescription drug
benefits shall comply with all of the following requirements:
   (1) Provide notice to enrollees regarding the use of a formulary.
The notice shall be in language that is easily understood and in a
format that is easy to understand.  The notice shall include an
explanation of what a formulary is, how the plan determines which
prescription drugs are included or excluded, and how often the plan
reviews the contents of the formulary.  Every plan shall provide
notice to enrollees regarding the rights of an enrollee when the
enrollee's health care provider prescribes a drug that does not
appear on the plan's formulary.
   (2) Furnish to any prospective or current enrollee, upon request,
a current copy of the plan's complete formulary.
   (3) Furnish to any prospective or current enrollee, upon request,
the list of drugs contained in the plan's formulary for a specific
medical condition.
   (4) Provide access to prospective or current enrollees, through a
toll-free phone number, to information regarding whether a specific
drug or drugs is on the plan's formulary.  Notice of this
requirement, including the plan's toll-free phone number, shall be
included in the notice required by paragraph (1).
  SEC. 2.  No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB 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 XIIIB of the California Constitution.
   Notwithstanding Section 17580 of the Government Code, unless
otherwise specified, the provisions of this act shall become
operative on the same date that the act takes effect pursuant to the
California Constitution.