The Schwarzenegger administration released Tuesday what one official called the clearest and most comprehensive regulations in the nation governing HMO pharmaceutical benefits.
The proposed rules, which must still undergo a public comment period and approval by a state administrative law judge, will require health maintenance organizations to provide all "medically necessary" drugs.
Administration officials acknowledge that some of the regulations only codify current practices, but they also maintain that the new rules will make it harder for HMO to deny drugs that patients need.
"With these new regulations, there will be no doubt in a patient's mind as to which drugs are covered, and the vast majority of prescription drugs will be available to consumers," said Cindy Ehnes, director of the Department of Managed Health Care during a Tuesday morning press conference.
The regulations will require that HMOs wanting to exclude prescription drugs offer medical evidence for the exclusion and also get the approval of Ehnes.
In addition, the regulations will require that drug co-payments not exceed 50 percent of a drug's price, and that any drug exclusions be published on an HMO's Web site, among other requirements.
The department was required to issue the regulations under a law that was passed in 2002 and authored by state Sen. Jackie Speier, who voiced support of the proposed rules during the press conference.
A spokesman for the California Association of Health Plans, an industry trade group, downplayed the significance of the new rules, saying they required in most cases what is already common practice among insurers.
"This regulation is really more focused on process," said spokesman Bobby Pena. "Still, there are things we want to look at. When a piece of legislation works its way into regulations you want to make sure they didn't overstep the bounds of the legislation."
A key area that the regulations will target is the recent practice of health plans moving entire classes of drugs off their list of preferred or covered drugs once one drug is placed on over-the-counter status. That happened with several non-drowsy allergy medications once Claritin was available over-the-counter.
The regulations are expected to go into effect later this year. The administration's announcement came the day before the governor, under pressure from Democrats, was expected to announce a plan in his State of the State address to reduce the cost of prescription drugs for Californians.
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