Prescription drug coverage: dose adjustments.

Plain English Breakdown

The official summary does not provide specific details on when the bill will take effect or what conditions must be met for dose adjustments.

Prescription Drug Coverage: Dose Adjustments

The bill allows doctors to adjust the dose or frequency of prescription drugs without prior approval from insurance companies if certain conditions are met.

What This Bill Does

• Allows a licensed health care professional, who is an enrollee’s or insured person's treating provider, to request and be granted permission to adjust the amount or how often a patient takes their medicine if it's needed for medical reasons.
• Requires health plans not to limit coverage for medicines that patients have been taking continuously for their condition.

Who It Names or Affects

• Patients who take prescription drugs
• Doctors who prescribe medicine
• Health insurance companies

Terms To Know

Utilization review

A process where doctors check if medical treatments are necessary before approving them.

Enrollee

Someone who is part of a health insurance plan.

Limits and Unknowns

• The bill does not specify when it will start to be used.
• It only applies to people with prescription drug coverage from health care service plans or health insurers in California.

Official Summary Text

SB 964, as amended, Smallwood-Cuevas.
Prescription drug coverage: dose adjustments.
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 authorizes a health care service plan or health insurer to use utilization review, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law also prohibits a health care service plan that covers prescription drug benefits from limiting or excluding coverage for a drug that was previously approved for coverage if an enrollee continues to be prescribed that drug, as
specified.
This bill would authorize
a licensed health care professional
an enrollee’s or insured’s treating provider
to request, and would require that they be granted, the authority to adjust the dose or frequency of a drug to meet the specific medical needs of the enrollee or insured without prior authorization if specified conditions are met.
Under the bill, if the enrollee or insured has been continuously using a prescription drug selected by their prescribing provider for the medical condition under consideration while covered by their current or previous health coverage, the health care service plan or health insurance policy would be prohibited from limiting or excluding coverage of that prescription.
Because a willful violation of these provisions by a health care service plan 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.

Current Bill Text

Download Bill PDF