BILL NUMBER: AB 1977INTRODUCED BILL TEXT INTRODUCED BY Assembly Members Wood and Waldron FEBRUARY 16, 2016 An act to add Section 1367.217 to the Health and Safety Code, and to add Section 10123.203 to the Insurance Code, relating to health coverage. LEGISLATIVE COUNSEL'S DIGEST AB 1977, as introduced, Wood. Health coverage: abuse-deterrent opioid analgesics. 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 that act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. These provisions require specified services and drugs to be covered by the various health care service plans and health insurers. This bill would require an individual or group health care service plan or disability insurance policy issued, amended, or renewed after January 1, to provide coverage on its formulary, drug list, or other lists of similar construct for at least one abuse-deterrent opioid analgesic drug product per opioid analgesic active ingredient. The bill would require that the total amount of copayments and coinsurance an enrollee or insured is required to pay for brand name abuse-deterrent opioid analgesic drug products covered pursuant to the bill not exceed the lowest cost-sharing level applied to brand name or generic prescription drugs covered under the applicable health care service plan or insurer, as specified. The bill would prohibit a health care service plan or insurer from requiring an enrollee or an insured to first use a non-abuse-deterrent opioid analgesic drug product before providing coverage for an abuse-deterrent opioid analgesic drug product, subject to uniformly applied utilization review requirements described in the bill. Because a willful violation of these requirements with respect to health care service plans 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. 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. The Legislature finds and declares as follows: (a) Abuse and misuse of opioids is a serious problem that affects the health, social, and economic welfare of the state. (b) After alcohol, prescription drugs are the most commonly abused substances by Americans over 12 years of age. (c) Almost 2,000,000 people in the United States suffer from substance use disorders related to prescription opioid pain relievers. (d) Nonmedical use of prescription opioid pain relievers can be particularly dangerous when the products are manipulated for snorting, injection, or combination with other drugs. (e) Deaths involving prescription opioid pain relievers represent the largest proportion of drug overdose deaths, greater than the number of overdose deaths involving heroin or cocaine. (f) The number of unintentional overdose deaths involving prescription opioid pain relievers has more than quadrupled since 1999. SEC. 2. Section 1367.217 is added to the Health and Safety Code, to read: 1367.217. (a) Notwithstanding any other law, an individual or group health care service plan issued, amended, or renewed on or after January 1, that provides coverage for an opioid analgesic drug product shall comply with all of the following: (1) The plan shall provide coverage on its formulary, drug list, or other lists of similar construct for at least one abuse-deterrent opioid analgesic drug product per opioid analgesic active ingredient. (2) Notwithstanding any deductible, the total amount of copayments and coinsurance an enrollee is required to pay for brand name abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to brand name prescription drugs covered under the applicable health care service plan. (3) Notwithstanding any deductible, the total amount of copayments and coinsurance an enrollee is required to pay for generic abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to generic prescription drugs covered under the applicable health care service plan. (4) The plan shall not require an enrollee to first use a non-abuse-deterrent opioid analgesic drug product before providing coverage for an abuse-deterrent opioid analgesic drug product. This paragraph shall not be construed to prevent a health care service plan from applying utilization review requirements, including prior authorization, to abuse-deterrent opioid analgesic drug products, provided that those requirements are applied to all opioid analgesic drug products with the same type of drug release, immediate or extended. (b) The following definitions shall apply for purposes of this section: (1) "Abuse-deterrent opioid analgesic drug product" means a brand or generic opioid analgesic drug product approved by the federal Food and Drug Administration (FDA) with abuse-deterrence labeling claims indicating its abuse-deterrent properties are expected to deter or reduce its abuse. (2) "Cost sharing" means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirement. (3) "Opioid analgesic drug product" means a drug product that contains an opioid agonist and that is indicated by the FDA for the treatment of pain, whether in an immediate release or extended release formulation and whether or not the drug product contains any other drug substance. SEC. 3. Section 10123.203 is added to the Insurance Code, to read: 10123.203. (a) Notwithstanding any other law, an insurer issuing, amending, or renewing a policy of individual or group disability insurance on or after January 1, that provides coverage for an opioid analgesic drug product shall comply with all of the following: (1) The insurer shall provide coverage on its formulary, drug list, or other lists of similar construct for at least one abuse-deterrent opioid analgesic drug product per opioid analgesic active ingredient. (2) Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay for brand name abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to brand name prescription drugs covered under the applicable policy. (3) Notwithstanding any deductible, the total amount of copayments and coinsurance an insured is required to pay for generic abuse-deterrent opioid analgesic drug products covered pursuant to this section shall not exceed the lowest cost-sharing level applied to generic prescription drugs covered under the applicable policy. (4) The insurer shall not require an insured to first use a non-abuse-deterrent opioid analgesic drug product before providing coverage for an abuse-deterrent opioid analgesic drug product. This paragraph shall not be construed to prevent an insurer from applying utilization review requirements, including prior authorization, to abuse-deterrent opioid analgesic drug products, provided that those requirements are applied to all opioid analgesic drug products with the same type of drug release, immediate or extended. (b) The following definitions shall apply for purposes of this section: (1) "Abuse-deterrent opioid analgesic drug product" means a brand or generic opioid analgesic drug product approved by the federal Food and Drug Administration (FDA) with abuse-deterrence labeling claims indicating its abuse-deterrent properties are expected to deter or reduce its abuse. (2) "Cost sharing" means any coverage limit, copayment, coinsurance, deductible, or other out-of-pocket expense requirement. (3) "Opioid analgesic drug product" means a drug product that contains an opioid agonist and that is indicated by the FDA for the treatment of pain, whether in an immediate release or extended release formulation and whether or not the drug product contains any other drug substance. 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.