California program
A cost cap for covered chemotherapy pills
A California limit on what you pay for covered chemotherapy pills, when the state’s rule applies to your plan.
What it is
A California limit on what you pay for covered chemotherapy pills, when the state’s rule applies to your plan.
This cap is the check when a covered chemo pill comes with a large pharmacy charge. It applies to plans California regulates; a plan where the employer pays its own claims does not have to follow it, and HR can say which yours is. The cap limits the price of a covered drug; it does not make an excluded drug covered.
Who can get it
- The cap covers oral anticancer drugs that your fully insured DMHC- or CDI-regulated plan covers.
- Non-grandfathered individual and small-group plans have a separate prescription limit. It is generally $250 for each covered prescription lasting up to 30 days, or $500 for a bronze plan, with deductible rules. The oral anticancer cap needs its own check even when another general prescription limit applies.
- An HSA-qualified high-deductible plan is not completely excluded. The oral anticancer cap applies after the applicable deductible is met. The drug must be covered and the state law must reach the plan. Private self-funded employer plans are generally outside this mandate.
What you get
- No more than $250 per covered oral anticancer prescription for up to a 30-day supply when the cap applies.
- Individual and small-group plans have a broader cap for covered outpatient prescriptions.
If you decide to apply
- Ask the pharmacy and plan member-services team to check a chemotherapy-pill charge against the cap.
- Have ready: the pharmacy receipt, drug name, days supplied, plan card and benefit summary.
1-888-466-2219 DMHC. 1-800-927-4357 CDI · Official page ↗
What happens next
- A corrected pharmacy claim may produce a reduced charge or refund. A dispute can go through the plan complaint process and regulator.
- The plan’s written explanation should identify the coverage rule or exemption it used.
Good to know
On an HSA-qualified high-deductible plan, the cap starts once the deductible is met. Keep the receipt and the insurance statement; the pharmacy can check the charge against the cap.
What else to know
- A CalPERS, school-district or local-government plan needs a document-specific review. Private self-funded exclusions cannot simply be applied by employer name.
- California has no single rule on whether a drug maker's copay card counts toward your deductible. Ask the plan how it treats that payment.
Official sources
“Would the chemotherapy-pill cap apply to our plan and prescription, and what deductible rules remain? Is there a charge we should ask to have corrected, and could you help us contact the pharmacy and plan?”
Why I’m asking: I want to know whether a state cost cap would apply to a covered cancer prescription.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
If a chemo-pill copay is over $250, ask the pharmacy to rerun it and ask the plan for the calculation in writing.
Your social worker
The social worker or clinic pharmacist can confirm the drug is a covered oral anticancer drug and help with the complaint.
The care team
Records and letters when the application asks for them.
- Who decides
- The health plan, with DMHC or CDI enforcing on complaint
- Ask the billing office
- “California caps covered chemo pills at $250 a fill. Can you check this bill and the deductible exception, and explain any refusal in writing?”
How to apply
First step: If a covered chemo-pill copay exceeds $250, ask the pharmacy to rerun it and the plan for its calculation. If refused, complain to the plan and call DMHC at 1-888-466-2219.
- Ask the pharmacy to rerun a copay over $250.
- Ask the plan for the written calculation
- File a grievance and call DMHC if refused.
Where it starts: Plan complaint, then regulator
What to gather
- The pharmacy receipt
- The plan card and benefit summary
- The drug name and days' supply
How long: A pharmacy rerun is same day. A complaint is 30 days at most.
What a yes looks like
A refund or reprocessed claim at $250 or less per fill.
What a no looks like, and the next move
The plan explains the covered-drug, jurisdiction and deductible rules in writing. An HSA-qualified plan is not wholly excluded; the regulator can review whether the applicable deductible and cap were used.
Watch out
- Self-funded plans follow federal law only. Ask HR whether the plan follows the cap voluntarily.
- An HSA-qualified high-deductible plan is not a blanket exception: the oral anticancer cost-sharing limit applies after the applicable deductible has been satisfied. The drug must be covered, and the state law must reach the plan. A private self-funded employer plan generally is outside this state mandate.
- Only covered drugs. A non-covered drug is an appeal, not a cap question.
- The separate general prescription limit for non-grandfathered individual and small-group coverage is not the same rule: it is generally $250 per covered prescription for up to 30 days, or $500 for a bronze plan, with deductible qualifications. The oral anticancer rule needs its own check even when a different general prescription limit applies.
- CalPERS Kaiser’s 2026 plan has its own appeal and fertility-preservation terms. Other CalPERS, school-district and local-government plans need their own document check. Ask the administrator before applying the private self-funded-plan exclusion.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 10, 2026.
What it is worth
No more than $250 out of pocket for each 30-day fill of a covered oral chemo drug on a state-regulated plan.
- $250 — Maximum cost sharing per prescription per up-to-30-day supply
Legal protection: Cost-sharing cap on covered oral anticancer drugs, California law / Ins. Code 10123.206 · On an individual or small-group plan, every covered outpatient prescription is capped at $250 per up-to-30-day supply (antifungals, growth-factor pens and the like), not only chemo pills
What it costs the family: Up to $250 per fill.
The eligibility facts, as published
- Plan type
- fully insured, DMHC or CDI regulated
- Excluded
- Private self-funded employer plans generally fall outside the state mandate; public-employer plans require document-specific review.
- Drugs
- covered oral anticancer drugs
- Hsa deductible
- For HSA-qualified high-deductible plans, the cost-sharing cap applies after the applicable deductible is satisfied.
Decisions this site cannot make: Plan regulator and funding type
Expect friction on: Pharmacy must rerun the claim
The trap: The cap applies only to covered oral anticancer drugs. A non-covered drug is a coverage appeal, not a cap question.
Where I read this
- Health and Safety Code 1367.656 (oral anticancer cost-sharing cap) — California Legislature (leginfo), read September 8, 2026
- Health and Safety Code 1342.73 (outpatient prescription cost-sharing cap) — California Legislature (leginfo), read September 8, 2026
- Kaiser CalPERS 2026 EOC — choose.kaiserpermanente.org, read September 10, 2026
- Kaiser CalPERS 2026 EOC — choose.kaiserpermanente.org, read September 10, 2026