Bill(s)

2021 AB 718 and 2021 SB 753 prohibit an insurer offering a health benefit plan, a pharmacy benefit manager, or an agent of the insurer or pharmacy benefit, from:

  • Refusing to authorize, approve, or pay a participating provider for providing a covered clinician-administered drug and related services to an enrollee, policyholder, or insured.
  • Condition, deny, restrict, refuse to authorize or approve, or reduce payment to a participating provider for a covered clinician-administered drug and related services when all criteria for medical necessity are met because the provider obtains the drug from an entity that is not selected by the plan.
  • Prohibit health benefit plan designs that prevent participating providers from receiving reimbursement for a covered clinician-administered drug and any related services at an applicable rate as specified in the contract.
  • Impose coverage or benefit limits, or require an enrollee, policyholder, or insured to pay an additional fee, higher copay or coinsurance, second copay or coinsurance, or penalty when obtaining a clinician administered drug from an authorized health care provider or pharmacy.
  • Require an enrollee, policyholder, or insured to pay an additional fee, higher copay or coinsurance, second copay or coinsurance, or other form of a price increase for a clinician-administered drug when the drug is not dispensed by a pharmacy or acquired from an entity that is selected by the plan
  • Interfere with an enrollee’s, policyholder’s, or insured’s right to choose to obtain a clinician-administered drug from a participating provider or pharmacy of choice.
  • Limit or exclude coverage for a clinician-administered drug when not dispensed by a pharmacy or acquired from an entity selected by the plan when the drug would otherwise be covered.
  • Require a pharmacy to dispense a clinician-administered drug directly to an enrollee, policyholder, insured, or the insured’s agent with the intention that the individual will transport the drug to a health care provider for administration.
  • Require or encourage the dispensing of a clinician-administered drug to an enrollee, policyholder, or insured in a manner that is inconsistent with the federal Drug Supply Chain Security Act.
  • Require that a clinician-administered drug be dispensed or administered to an enrollee, policyholder, or insured in the residence of the enrollee, policyholder, or insured or required the use of an infusion site external to the office or clinic of the enrollee’s, policyholder’s, or insured’s provider.

Sponsors

2021 AB 718 was introduced by Rep. Kurtz and referred to the Assembly Committee on Health. 2021 SB 753 was introduced by Sen. Darling and referred to the Senate Committee on Insurance Licensing and Forestry. 

Status

Failed to pass pursuant to Senate Joint Resolution 1

Other

Please contact Tarna Hunter, ETF’s Government Relations Director, if you have any questions.