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AB 1366

Reimbursement for pharmacist services.

2025-2026 Regular Session Introduced by Heath Flora

The bill raises Medi-Cal and private payer reimbursement for pharmacist services to parity with physician rates and requires plans and insurers to pay pharmacists enrolled as provi

In committee: Held under submission.
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Bill Summary · AB 1366

AB 1366 — Reimbursement for pharmacist services (Flora) — Summary

Status: Introduced Feb 21, 2025; re-referred to Assembly Committee on Health (most recent action Apr 1, 2025).
Primary code sections amended: Health & Safety Code §1368.5; Insurance Code §10125.1; Welfare & Institutions Code §14132.968.

Purpose / Intent

AB 1366 would expand and standardize payment for pharmacist-provided clinical services across Medi‑Cal, licensed health care service plans, and disability insurers by:

  • Raising the Medi‑Cal reimbursement rate for pharmacist services to match the physician fee schedule (instead of the current 85% level), including medication therapy management (MTM); and
  • Requiring commercial plans and disability insurers that cover pharmacist services to pay or reimburse services performed by pharmacists who are enrolled as providers with the plan/insurer (in-network or under an out‑of‑network pharmacy benefit).

The bill also states the Legislature’s intent to consider future legislation to establish or clarify pharmacists’ standard of care.

Key provisions

  • Medi‑Cal (Welfare & Institutions Code §14132.968)

    • Pharmacist services remain a Medi‑Cal benefit (subject to federal approval).
    • The department must establish a pharmacist fee schedule.
    • Reimbursement rate for pharmacist services is changed from 85% of the physician fee schedule to parity with the physician fee schedule (100% of physician rates), explicitly including MTM pharmacist services.
    • Directs the Department of Health Care Services to implement an MTM reimbursement methodology tied to use of drugs so Medi‑Cal payments are made only to eligible pharmacists or pharmacies for MTM services connected to certain specialty drug therapy categories.

  • Health care service plans (Health & Safety Code §1368.5)

    • Plans that cover services within a pharmacist’s scope must pay or reimburse services performed by:
    • an in‑network pharmacist/pharmacy,
    • an out‑of‑network pharmacist when the plan has an out‑of‑network pharmacy benefit, or
    • a pharmacist enrolled as a provider with the plan.
    • Payment may be made when the service is within the pharmacist’s lawful scope and the coverage would otherwise reimburse identical or similar services by other licensed providers.

  • Disability insurers (Insurance Code §10125.1)

    • Parallel changes require insurers that cover hospital/medical/surgical expenses to pay/reimburse pharmacist services under the same conditions described for plans.

  • Enforcement/State mandates

    • Because willful Knox‑Keene violations are criminalized, the bill may create a state‑mandated local program. The bill includes a provision stating no state reimbursement is required under specified constitutional provisions.

Who would be affected

  • Pharmacists and pharmacies (especially those enrolled as providers) — broader ability to be paid for clinical services and MTM tied to specialty drugs.
  • Medi‑Cal beneficiaries — potentially improved access to pharmacist-provided services.
  • Managed care plans and disability insurers — new payment/reimbursement obligations when pharmacist services are covered.
  • State budget and Medi‑Cal program — likely upward pressure on expenditures due to higher reimbursement rates (from 85% to parity with physician fee schedule), though the bill’s fiscal analysis is not included in the text.

Procedural / timeline notes

  • Introduced Feb 21, 2025; read first time Feb 24; amended and re‑referred to Assembly Health March 28; re‑referred Apr 1, 2025.
  • Further hearings and fiscal committee review may occur as the bill moves through the Legislature.

Considerations

  • The move from 85% to parity with physician rates would increase provider payment levels; fiscal impact on Medi‑Cal and insurers should be analyzed.
  • The bill tightens eligibility and payment controls for MTM tied to specialty drug therapy categories.
  • The author signals intended future legislation on pharmacist standard-of-care, which could further affect practice scope and liability.

Compiled from official sources — confirm details with the bill’s official record.

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