AB 714

This bill imposes requirements on employee benefit plan administrators, insurers for large group health benefit plans, and pharmacy benefit managers regarding the ability of a plan sponsor (for example, an employer) to access claims data and other information. The bill requires that a contract between an administrator, insurer, or pharmacy benefit manager and a plan sponsor to provide services must specify that the plan sponsor owns the claims data relating to the contract. The bill also provides that claims data may not be sold to any party without the permission of the plan sponsor and the individual to whom the claims data relates.

Under the bill, an administrator, insurer, or pharmacy benefit manager must provide certain information to the plan sponsor or the plan sponsor’s designee within seven business days upon request. An administrator or insurer must provide claims data and payments, the amounts of fees and discounts, and, if requested, itemized billing statements and medical records associated with a specific claim. A pharmacy benefit manager must provide prescription drug claims and payments, rebate amounts provided by pharmaceutical manufacturers, and the amounts of revenue and fees derived from the contract. The bill allows the plan sponsor or designee to request information three times per plan year, and each request may be for up to 24 months of data.

The bill prohibits an administrator, insurer, or pharmacy benefit manager from imposing a fee for requesting the information that exceeds the expenses reasonably incurred to provide the information and any condition restricting the plan sponsor’s or designee’s right to access the information.

Also under the bill, an administrator or insurer must provide, within seven business days of a written request, information about a claim exceeding or expecting to exceed $25,000, which is reduced to $10,000 for a pharmacy claim. The bill further requires that a pharmacy benefit manager provide, within seven business days of a written request, data regarding the amounts paid to a pharmacy or pharmacist on behalf of the plan sponsor.

Finally, the bill provides that the claims data and other information may not be modified or withheld from a plan sponsor or the plan sponsor’s privacy officer or other designee if the plan sponsor, privacy officer, or designee attests that the information will be used and disclosed only as permitted or required under federal laws and regulation.