California Health and Safety Code

§ 1367.206

HSC § 1367.206 Effective Jan 1, 2024Div. 2 · Ch. 2.2 · Art. 5

Statute text

(a)If there is more than one drug that is clinically appropriate for the treatment of a medical condition, a health care service plan that provides coverage for prescription drugs may require step therapy.

(b)A health care service plan shall expeditiously grant a request for a step therapy exception within the applicable time limit required by Section 1367.241 if a prescribing provider submits necessary justification and supporting clinical documentation supporting the provider’s determination that the required prescription drug is inconsistent with good professional practice for provision of medically necessary covered services to the enrollee, taking into consideration the enrollee’s needs and medical history, along with the professional judgment of the enrollee’s provider. The basis of the provider’s determination may include, but is not limited to, any of the following criteria:

(1)The required prescription drug is contraindicated or is likely, or expected, to cause an adverse reaction or physical or mental harm to the enrollee in comparison to the requested prescription drug, based on the known clinical characteristics of the enrollee and the known characteristics and history of the enrollee’s prescription drug regimen.

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Legislative history

Amended by Stats. 2023, Ch. 495, Sec. 1. (SB 621) Effective January 1, 2024.