STATE CANNOT
MANDATE DRUG BENEFITS - KAISER V. ZINGALE
In Kaiser Foundation Health Plan, Inc. v. Zingale
(2002) 02 CDOS 5848, the state Department of Managed Health Care rejected
a health plan’s proposed amendment to its plan that discontinued benefits
for prescription drugs to treat sexual dysfunction. The plan contended
that the state lacked authority to require it to provide benefits for
specific drugs.
The Court of Appeal held that the state did lack
authority to require plans to provide benefits for specific drugs used for
particular medical conditions. State law protects patients from overly
restrictive drug formularies, but allowed health plans to limit the
medical conditions for which prescription drugs are covered. Thus, the
court held that the health plan could amend its plan language to exclude
benefits for drugs used to treat sexual dysfunction.
