Health care coverage: prescription hormone therapy and nondiscrimination.

Senator Menjivar, joined by Senator Cervantes and Assembly Member Bonta, advances a measure that ties health coverage to a 12-month supply of FDA‑approved prescription hormone therapy and the necessary self‑administration supplies when prescribed within a network provider’s scope and dispensed at one time, signaling a shift in how hormone therapy is billed across private plans and public coverage. The findings describe an intent to expand the state’s prescription hormone therapy coverage policy to require this 12‑month supply across health care service plans, health insurers, and Medi‑Cal.

The central changes apply to outpatient prescription drug benefits offered by health care service plans and insurers, plus Medi‑Cal, with several notable details. Plans would be prohibited from using utilization controls or medical management that reduce the supply to less than 12 months. If a patient or prescribing provider requests a smaller initial supply, or if the prescribing provider directs a smaller supply, or if a temporary shortage limits refills to a 90‑day quantity, those circumstances would permit deviations. For prescription hormone therapy that is a controlled substance, the maximum supply allowed under state and federal law would be dispensed at one time. The measure allows last‑quarter refills to be limited if a 12‑month supply has already been dispensed within the year, and it does not require in‑network coverage for out‑of‑network prescriptions, except where required by law or policy; Medi‑Cal managed‑care plans contracting with the state are excluded from these requirements. The term “prescription hormone therapy” is defined as FDA‑approved drugs used to suppress, increase, or replace hormones, excluding GLP‑1s, with storage considerations limited to those that can be kept safely at room temperature. The policy would take effect immediately as an urgency statute and would terminate on January 1, 2035.

In addition to access and coverage, the measure embeds nondiscrimination protections. It prohibits enrollment denials, benefit denials, or discriminatory treatment by health plans or insurers on the basis of race, color, national origin, age, disability, or sex, with “sex” encompassing sex characteristics (including intersex traits), pregnancy, sexual orientation, gender identity, and related considerations. The bill enumerates specific prohibitions in access to programs and services, including restrictions based on birth sex or gender identity, and prohibits coverage denials or limitations tied to gender transition or other gender‑affirming care in discriminatory ways. Notices to enrollees must include statements that discrimination is not allowed, how to file grievances, and contact information for filing, with the protections and remedies described as cumulative with other laws and regulations. Violations are treated as crimes under the bill’s framework, reflecting the authors’ view that enforcement is essential to the policy’s scope.

Implementation provisions outline federal‑level coordination and program boundaries. The Medi‑Cal portion would cover up to a 12‑month supply for beneficiaries, subject to medical necessity and existing utilization controls, limited to room‑temperature‑stable products, and with stated exceptions for out‑of‑network access when in‑network supply is unavailable. The department would pursue federal approvals as needed to implement Medi‑Cal coverage, and the section excludes Medi‑Cal managed care plans under certain circumstances. Definitions establish the meaning of “provider” and the intended scope of products covered, with a set‑aside for room‑temperature storage and a sunset date of 2035. The act emphasizes an immediate effect while situating tighter implementation within federal compatibility and program rules, and it notes that no local reimbursement is required for costs arising from the bill. In the broader policy context, the measure sits alongside existing protections and coverage requirements for related reproductive and gender‑affirming care and aligns with ongoing efforts to standardize coverage for medically necessary hormone therapies across both private and public programs.