CaliforniaHealth plans would count qualifying help toward drug costs
Most health plans and insurers would count qualifying payments for covered prescription drugs, including some manufacturer help, toward a person’s cost limits and deductible.
What it does
Most covered plans would count qualifying payments for prescription drugs, including permitted manufacturer help, toward a person’s cost limit and in-network deductible. Exceptions apply when certain lower-cost alternatives are available.
The Insurance Commissioner could fine health insurers that violate the counting rules, after notice and a chance to be heard.
Argument forPatients using manufacturer help may reach their plan’s cost limit sooner, which could reduce what they pay later for covered care.
Argument againstPeople may worry that counting manufacturer help less often when cheaper alternatives exist could leave patients paying more toward their deductible for a needed brand drug.
More detail
Plans and insurers would count qualifying payments for covered drugs toward a person’s cost sharing, annual limit, and in-network deductible. This applies to most non-grandfathered health plans and insurance policies that provide essential health benefits. It excludes grandfathered coverage, certain specialized or supplemental coverage, and accident-only, specified-disease, and hospital-indemnity coverage. Payments made on a person’s behalf count only when the pharmacy tells the plan or insurer who received the help and how much was provided. The amount does not count when a lower-tier generic, an equally or less costly covered biosimilar, or a lower-cost nonprescription product with the same active ingredients is available and suitable; these exceptions do not apply when the person has legal coverage for a medically necessary nonpreferred or nonformulary drug. Manufacturer support remains subject to existing legal limits, and certain manufacturer payments are excluded. No start date is stated in the supplied text.
The Insurance Commissioner would be able to assess administrative penalties against insurers for violations. The penalties apply to health insurers that violate the bill’s requirements. The commissioner must provide appropriate notice and an opportunity for a hearing before ordering a penalty. The penalty may be up to $5,000 per violation, or up to $10,000 per violation if it was willful. No start date is stated in the supplied text.
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Where it stands
- Introduced
- Passed Senate
- Passed Assembly
- To Governor
- Became Law
Looking ahead
No hearings or votes scheduled.
History
- 2026
- Aug 13August 13 hearing: Held in committee and under submission.Latest
- Aug 5August 5 set for first hearing. Placed on suspense file.
- Jul 2Read second time and amended. Re-referred to Com. on APPR.Major
- Jul 1From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 13. Noes 0.) (June 30).Major
- Jun 30
- Vote recorded Do pass as amended and be re-referred to the Committee on [Appropriations]. Result: pass.Lower
- Jun 1Referred to Com. on HEALTH.Minor
- May 22In Assembly. Read first time. Held at Desk.Minor
- Vote recorded 3rd Reading SB1199 Weber Pierson. Result: pass.Upper
- May 22Read third time. Passed. (Ayes 26. Noes 0. Page 4413.) Ordered to the Assembly.Passed Senate
- May 14Read second time. Ordered to third reading.Minor
- Vote recorded Do pass. Result: pass.Upper
- May 14From committee: Do pass. (Ayes 5. Noes 0. Page 4268.) (May 14).Minor
- May 8Set for hearing May 14.
- May 4May 4 hearing: Placed on APPR. suspense file.
- Vote recorded Placed on suspense file. Result: pass.Upper
- Apr 28Set for hearing May 4.
- Apr 27Read second time and amended. Re-referred to Com. on APPR.Major
- Apr 23From committee: Do pass as amended and re-refer to Com. on APPR. (Ayes 9. Noes 0. Page 4011.) (April 22).Major
- Apr 22
- Vote recorded Do pass as amended, but first amend, and re-refer to the Committee on [Appropriations]. Result: pass.Upper
- Apr 13Set for hearing April 22.
- Mar 4Referred to Com. on HEALTH.Minor
- Feb 20From printer. May be acted upon on or after March 22.
- Feb 19Introduced. Read first time. To Com. on RLS. for assignment. To print.Introduced
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