Health care coverage: antiretroviral drugs, drug devices, and drug products.

Plain English Breakdown

The bill summary and digest do not specify that violating the provisions would be a criminal offense; they only state that willful violations by health care service plans would be crimes under existing law.

Health care coverage: antiretroviral drugs, drug devices, and drug products

The bill prohibits health care service plans and insurers from requiring prior authorization or step therapy for antiretroviral drugs, drug devices, or drug products used to prevent HIV/AIDS and requires them to cover these items as outpatient prescription benefits starting January 1, 2027.

What This Bill Does

• Prohibits health care service plans and insurers from requiring prior authorization or step therapy for antiretroviral drugs, drug devices, or drug products used to prevent HIV/AIDS.
• Requires health insurance policies issued, amended, or renewed on or after January 1, 2027, to cover non-self-administered antiretroviral drugs, drug devices, or drug products approved by the FDA for the prevention of HIV/AIDS as outpatient prescription benefits.

Who It Names or Affects

• Health care service plans and insurers
• People with HIV/AIDS who need antiretroviral drugs

Terms To Know

Prior authorization

A process where a health plan needs to approve a drug or treatment before it can be used.

Step therapy

A requirement that patients try less expensive drugs first before getting more costly ones.

Limits and Unknowns

• The bill does not apply to Medi-Cal managed care plans.
• It only applies to health insurance policies issued, amended, or renewed on or after January 1, 2027.

Official Summary Text

SB 1023, as amended, Laird.
Insurance: unlawful financial benefits.
Health care coverage: antiretroviral drugs, drug devices, and drug products.
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 provides for the regulation of health insurers by the Department of Insurance. Existing law generally prohibits a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs that are medically necessary for the prevention of HIV/AIDS, including preexposure prophylaxis or postexposure prophylaxis, to prior authorization or step therapy. Under existing law, a health care service plan or health insurer is not required to cover all of the therapeutically equivalent versions of those drugs without prior
authorization or step therapy if at least one is covered without prior authorization or step therapy.
This bill would instead prohibit a health care service plan, excluding a Medi-Cal managed care plan, or health insurer from subjecting antiretroviral drugs, drug devices, or drug products that are medically necessary for the prevention of HIV/AIDS to prior authorization or step therapy. The bill would require a health care service plan contract or health insurance policy issued, amended, or renewed on or after January 1, 2027, that covers non-self-administered antiretroviral drugs, drug devices, or drug products that are approved by the United States Food and Drug Administration (FDA) for the prevention of HIV/AIDS as a medical benefit to also include those non-self-administered antiretroviral drugs, drug devices, or drug products as an outpatient prescription drug benefit. Because a willful violation of these provisions by a health care service plan would be a
crime, this 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.
Existing law creates the Department of Insurance to regulate the business of insurance. Existing law makes it a crime for a person engaging in the practice of processing, presenting or negotiating claims for policies of insurance to offer, deliver, receive or accept consideration, as specified, as compensation for the referral or procurement of clients or cases, among others. Existing law makes it unlawful for an insurance agent or broker to receive financial benefit from an automobile repair facility, or other specified consideration, for referring insureds to the facility for vehicle repairs covered under certain specified insurance policies issued by the agent or broker.
This bill would make technical, nonsubstantive changes to these provisions.

Current Bill Text

Download Bill PDF