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AMENDED IN SENATE MAY 14, 2026

AMENDED IN SENATE APRIL 6, 2026

CALIFORNIA LEGISLATURE— 2025–2026 REGULAR SESSION

96

Introduced by Senator Smallwood-Cuevas

February 3, 2026

An act to add Section 1367.225 to the Health and Safety Code, and to add Section 10123.1934 to the Insurance Code, relating to health care coverage.

Vote: majority   Appropriation: no   Fiscal committee: yes   Local program: yes

LEGISLATIVE COUNSEL’S DIGEST

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 the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Existing law generally authorizes a health care service plan or health insurer to use utilization review, under which a licensed physician or a licensed health care professional who is competent to evaluate specific clinical issues may approve, modify, delay, or deny requests for health care services based on medical necessity. Existing law also prohibits a health care service plan that covers prescription drug benefits from limiting or excluding coverage for a drug that was previously approved for coverage if an enrollee continues to be prescribed that drug, as specified.

This bill would authorize an enrollee’s or insured’s treating contracting provider to request, and would require that they be granted, submit a written request to a health care service plan or health insurer requesting the authority to adjust the dose or frequency of a drug to meet the specific medical needs of the enrollee or insured without prior authorization or subsequent utilization management. The bill would require the plan or insurer to issue a written response within 72 hours and to authorize the request if specified conditions are met. established in the request. Because a willful violation of these provisions by a health care service plan would be a crime, the 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.

The people of the State of California do enact as follows:

SECTION 1.

Section 1367.225 is added to the Health and Safety Code, to read:

1367.225.

(a) An enrollee’s treating contracting provider may request, and shall be granted, submit a written request to a health care service plan requesting the authority to adjust the dose or frequency of a drug to meet the specific medical needs of the enrollee without prior authorization or subsequent utilization management management. A health care service plan shall issue a written response to the requesting provider within 72 hours of receipt of the request, which shall authorize the request if all of the following conditions are met: established in the request:

(1) The drug previously had been approved for coverage by the plan for an enrollee’s chronic medical condition serious chronic condition, as defined in Section 1373.96, or cancer treatment and the enrollee’s treating provider continues to prescribe the drug for the enrollee’s serious chronic medical condition or cancer treatment.

(2) The drug is not an opioid or a scheduled controlled substance.

(3) The dose has not been adjusted more than two times without prior authorization.

(c) This section does not apply to a Medi-Cal managed care plan contracting with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), or Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.

SEC. 2.

Section 10123.1934 is added to the Insurance Code, to read:

10123.1934.

(a) An insured’s treating contracting provider may request, and shall be granted, submit a written request to a health insurer requesting the authority to adjust the dose or frequency of a drug to meet the specific medical needs of the insured without prior authorization or subsequent utilization management management. A health insurer shall issue a written response to the requesting provider within 72 hours of receipt of the request, which shall authorize the request if all of the following conditions are met: established in the request:

(1) The drug previously had been approved for coverage by the insurer for an insured’s chronic medical condition serious chronic condition, as defined in Section 10133.56, or cancer treatment and the insured’s treating provider continues to prescribe the drug for the insured’s serious chronic medical condition or cancer treatment.

(2) The drug is not an opioid or a scheduled controlled substance.

(3) The dose has not been adjusted more than two times without prior authorization.

SEC. 3.

No reimbursement is required by this act pursuant to Section 6 of Article XIIIB 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 XIIIB of the California Constitution.