Cal. INS § 10123.861 — California Code / Code ins / Division 2 / Part 2 / Chapter 1 / Article 1 / Section 10123.861
Section 10123.861
Status: in_force

(a) A health insurance policy that provides outpatient prescription drug benefits and is issued, amended, or renewed on or after the operative date of this section shall include coverage for United States Food and Drug Administration-approved treatments used to treat menopausal symptoms, as medically necessary, including, but not limited to, all of the following:

(1) Hormone therapy, including combination estrogen and hormone medicines, combination estrogen and progestin medicines, estrogen-only and progestin-only medicines, vaginal estrogen, and topical hormone therapy. This does not include glucagon-like peptide-1 or glucagon-like peptide-1 receptor agonists used solely for weight loss.

(2) Low-dose antidepressants.

(3) Anticonvulsants.

(4) Medications to prevent or treat osteoporosis.

(5) Nonhormonal medications for vasomotor-related symptoms.

(b) A health insurance policy that is issued, amended, or renewed on or after January 1, 2027, shall include a program to ensure insured individuals have access to current menopause information and covered items and services.

(c) For the program to satisfy subdivision (b), the insurer shall do all of the following:

(1) Provide, no later than July 1, 2027, and biannually thereafter, all contracted providers delivering primary care with information about current clinical care recommendations for menopause care, including hormone therapy, from the Menopause Society or other nationally recognized professional association. The insurer shall encourage providers delivering primary care to review the information.

(2) Establish and maintain a policy to reimburse providers for provision of services related to menopause care, including services integrated with primary care and obstetrician-gynecologist services. The policy shall identify the Current Procedural Terminology (CPT) codes for services commonly used to evaluate, diagnose, and treat symptoms resulting from menopause.

(3) Establish and maintain a policy to provide insured individuals who may experience menopause and who are 40 years of age and older with an annual menopause assessment during primary care and obstetrician-gynecologist appointments. Insured individuals may opt out of receiving the assessments. The policy shall include a copy of the assessment tool and information on how it was developed or chosen.

(4) Provide insured individuals who may experience menopause and who are 40 years of age and older with a notice that includes a definition of menopause and that lists the covered items and services used to evaluate and treat symptoms resulting from menopause. The first notice shall be sent within 60 days of the insured individual’s 40th birthday and shall be sent biannually thereafter. Insured individuals may opt out of receiving the notices. The notice shall include a description of at least all of the following types of federal Food and Drug Administration-approved items and services:

(A) Hormone therapy in the full range of formulations and methods of administration.

(B) Low-dose antidepressants.

(C) Anticonvulsants.

(D) Medications to prevent or treat osteoporosis.

(E) Nonhormonal medications for vasomotor-related symptoms.

(5) Establish and maintain a policy to contract with providers delivering primary care, including advanced practice providers such as licensed nurse practitioners and certified nurse-midwives, who hold a certification or credential in menopause care from a nationally recognized organization, such as the Menopause Society or other similar organization. The policy shall state what steps the insurer will take to incentivize providers to receive and maintain the certification or credential.

(d) The health insurer shall file with the commissioner within six months of the operative date of this statute the policies and notices specified in subdivision (c). The insurer shall also disclose the policies to network providers, provider groups, and delegated entities that may be impacted by the policies and notices and shall attest to that disclosure to the commissioner.

(e) Coverage for the treatment options pursuant to this section shall be provided without discrimination on the basis of gender expression or identity.

(f) This section does not apply to accident-only, specified disease, hospital indemnity, Medicare supplement, dental-only, or vision-only insurance policies, except to the extent they provide coverage for the treatment of symptoms resulting from menopause.

(g) For purposes of this section, “menopause” includes perimenopause, menopause, and postmenopause.