BILL NUMBER: SB 961 AMENDED
BILL TEXT
AMENDED IN ASSEMBLY JUNE 10, 2010
AMENDED IN SENATE APRIL 27, 2010
AMENDED IN SENATE MARCH 9, 2010
INTRODUCED BY Senator Wright
(Coauthors: Senators Cox, Negrete McLeod, and Strickland)
(Coauthor: Assembly Member Hall)
FEBRUARY 5, 2010
An act to add and repeal Section 1367.655 to
of the Health and Safety Code, and to add
and repeal Section 10123.205 to of
the Insurance Code, relating to health care coverage.
LEGISLATIVE COUNSEL'S DIGEST
SB 961, as amended, Wright. Health care coverage: cancer
treatment.
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.
Existing law requires health care service plan contracts and health
insurance policies to provide coverage for all generally medically
accepted cancer screening tests and requires those plans and policies
to also provide coverage for the treatment of breast cancer.
Existing law imposes various requirements on contracts and policies
that cover prescription drug benefits.
This bill , until January 1, 2015, would
prohibit require health care service plan
contracts and health insurance policies that provide coverage for
orally administered cancer medications from charging a
copayment for the medications in excess of 200% of the lowest
copayment required by the plan or policy for brand name medications
in the formulary of the plan or policy, as specified
cancer chemotherapy treatment to provide coverage for a prescribed,
orally administered, nongeneric cancer medication, as specified. The
bill would require a health care service plan or health insurer to
review the percentage cost share, as defined, for oral nongeneric
cancer medications and intravenous or injected nongeneric cancer
medications and to apply the lower of the 2 as the cost-sharing
provision for oral nongeneric cancer medications. The bill would
specify that its provisions do not apply to health care
service plan contracts or health insurance policies that do not
provide coverage for prescription drugs . The bill would
specify that its provisions do not apply to a health care benefit
plan, contract, or health insurance policy with the Board of
Administration of the Public Employees' Retirement System.
Because a willful violation of the bill's requirements relative to
health care service plans would be 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 1367.655 is added to the
Health and Safety Code , to read:
1367.655. (a) A health care service plan contract issued,
amended, or renewed on or after January 1, 2011, that provides
coverage for cancer chemotherapy treatment shall provide coverage for
a prescribed, orally administered, nongeneric cancer medication used
to kill or slow the growth of cancerous cells and shall review the
percentage cost share for oral nongeneric cancer medications and
intravenous or injected nongeneric cancer medications and apply the
lower of the two as the cost-sharing provision for oral nongeneric
cancer medications. A health care service plan contract shall not
provide for an increase in enrollee cost sharing for nongeneric
cancer medications to any greater extent than the contract provides
for an increase in enrollee cost sharing for other nongeneric covered
medications.
(b) For purposes of this section, "cost share" means copayment,
coinsurance, or deductible provisions applicable to coverage for
oral, intravenous, or injected nongeneric cancer medications.
(c) Nothing in this section shall be construed to require a health
care service plan contract to provide coverage for any additional
medication not otherwise required by law.
(d) Nothing in this section shall prohibit a health care service
plan from removing a prescription drug from its formulary of covered
prescription drugs.
(e) This section shall not apply to a health care service plan
contract that does not provide coverage for prescription drugs.
(f) This section shall not apply to a health care benefit plan or
contract entered into with the Board of Administration of the Public
Employees' Retirement System pursuant to the Public Employees'
Medical and Hospital Care Act (Part 5 (commencing with Section 22750)
of Division 5 of Title 2 of the Government Code).
(g) This section shall remain in effect only until January 1,
2015, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2015, deletes or extends
that date.
SEC. 2. Section 10123.205 is added to the
Insurance Code , to read:
10123.205. (a) A health insurance policy issued, amended, or
renewed on or after January 1, 2011, that provides coverage for
cancer chemotherapy treatment shall provide coverage for a
prescribed, orally administered, nongeneric cancer medication used to
kill or slow the growth of cancerous cells and shall review the
percentage cost share for oral nongeneric cancer medications and
intravenous or injected nongeneric cancer medications and apply the
lower of the two as the cost-sharing provision for oral nongeneric
cancer medications. A health insurance policy shall not provide for
an increase in insured cost sharing for nongeneric cancer medications
to any greater extent than the policy provides for an increase in an
insured's cost sharing for other nongeneric covered medications.
(b) For purposes of this section, "cost share" means copayment,
coinsurance, or deductible provisions applicable to coverage for
oral, intravenous, or injected nongeneric cancer medications.
(c) Nothing in this section shall be construed to require a health
insurance policy to provide coverage for any additional medication
not otherwise required by law.
(d) Nothing in this section shall prohibit a health insurer from
removing a prescription drug from its formulary of covered
prescription drugs.
(e) This section shall not apply to a health insurance policy that
does not provide coverage for prescription drugs.
(f) This section shall not apply to a policy of health insurance
purchased by the Board of Administration of the Public Employees'
Retirement System pursuant to the Public Employees' Medical and
Hospital Care Act (Part 5 (commencing with Section 22750) of Division
5 of Title 2 of the Government Code).
(g) This section shall remain in effect only until January 1,
2015, and as of that date is repealed, unless a later enacted
statute, that is enacted before January 1, 2015, deletes or extends
that date.
SEC. 3. 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.
SECTION 1. The Legislature finds and declares
all of the following:
(a) There are 10 million Americans currently living with cancer.
(b) Approximately 1.5 million new cases of cancer will be
diagnosed in the United States in 2010.
(c) In California, 27, 725 men and 26, 735 women are expected to
die from cancer this year.
(d) Nearly one out of every two Californians born today will
develop cancer at some point in their lives.
(e) It is likely that one in five Californians will die of cancer.
(f) It is the intent of the Legislature that a health plan or
insurer that includes on its formulary, or authorizes on the basis of
medical necessity, oral medications used to treat cancer shall not
require copayments or other charges for those medications at a level
that effectively makes the medication inaccessible to a patient.
SEC. 2. Section 1367.655 is added to the Health
and Safety Code, to read:
1367.655. (a) A health care service plan contract issued,
amended, or renewed on or after January 1, 2011, that provides
coverage for orally administered cancer medication used to kill or
slow the growth of cancerous cells shall not charge a copayment for
these medications in excess of 200 percent of the lowest copayment
required by the plan for brand name medications in the plan's
formulary.
(b) Nothing in this section shall prohibit a health care service
plan contract from requiring prior approval or authorization for the
use of any medication described in subdivision (a). However, if the
health care service plan contract authorizes the dispensing of the
medication for any reason, the copayment provisions of subdivision
(a) shall apply.
(c) Nothing in this section shall be construed to require a health
care service plan contract to provide coverage for any additional
medication not otherwise required by law. Nothing in this section
shall prohibit a health care service plan from providing differential
cost-sharing between generic and nongeneric orally administered
cancer medications.
(d) This section shall not apply to a health care benefit plan or
contract entered into with the Board of Administration of the Public
Employees' Retirement System pursuant to the Public Employees'
Medical and Hospital Care Act (Part 5 (commencing with Section 22750)
of Division 5 of Title 2 of the Government Code).
(e) For purposes of this section, "copayment" means a flat dollar
amount an enrollee pays, out-of-pocket, at the time of receiving a
health care service or when paying for a prescription, after any
applicable deductible. The term shall not be construed to include any
other forms of cost-sharing.
SEC. 3. Section 10123.205 is added to the
Insurance Code, to read:
10123.205. (a) A health insurance policy issued, amended, or
renewed on or after January 1, 2011, that provides coverage for
orally administered cancer medication used to kill or slow the growth
of cancerous cells shall not charge a copayment for these
medications in excess of 200 percent of the lowest copayment required
by the policy for brand name medications in the policy's formulary.
(b) Nothing in this section shall prohibit a health insurance
policy from requiring prior approval or authorization for the use of
any medication described in subdivision (a). However, if the policy
authorizes the dispensing of the medication for any reason, the
copayment provisions of subdivision (a) shall apply.
(c) Nothing in this section shall be construed to require a health
insurance policy to provide coverage for any additional medication
not otherwise required by law. Nothing in this section shall prohibit
a health insurer from providing differential cost-sharing between
generic and nongeneric orally administered cancer medications.
(d) This section shall not apply to a policy of health insurance
purchased by the Board of Administration of the Public Employees'
Retirement System pursuant to the Public Employees' Medical and
Hospital Care Act (Part 5 (commencing with Section 22750) of Division
5 of Title 2 of the Government Code).
(e) For purposes of this section, "copayment" means a flat dollar
amount an insured pays, out-of-pocket, at the time of receiving a
health care service or when paying for a prescription, after any
applicable deductible. The term shall not be construed to include any
other forms of cost-sharing.
SEC. 4. 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.