Issues_Proactive_Admin-Simp_1050
Issue Background

Uniform Prior Authorization

On October 1, 2014, the state began to implement the long-awaited Uniform Prescription Drug Prior Authorization Request Form.  Certain health plans in California will be required to implement the form, as well as abide by new timelines and notification procedures, when processing prior authorization requests for prescription drug benefits.

For your reference: "New Uniform Prescription Drug Prior Authorization Request Form and Notification Requirements for Health Plans in California" including background information, frequently asked questions, and form, courtesy of Johnson & Johnson Health Care Systems Inc.  Additional reference materials and health insurer provider updates included below.

On September 30, 2014, CRA hosted a Johnson & Johnson-sponsored webinar on the implementation of the new uniform prescription drug prior authorization form. For more information on the new law or CRA webinars, please contact info@calrheum.org.

California physicians rejoiced in October, 2011, after the Governor signed SB 866 into law, mandating the use of a uniform prior authorization form for prescription drug benefits, streamlining and improving the process. The long-awaited Prescription Drug Prior Authorization Request Form was finalized and adopted by the California Department of Managed Health Care in May, 2014.

The California Departments of Managed Health Care and Insurance were required by the law to jointly develop a uniform prior authorization form, which must meet certain criteria including:

1.         Not exceed two pages,

2.         Be electronically available by the state and health care service plan, and

3.         Be electronically submitted from the prescriber to the health care service plan. 

Pursuant to the law, a health care service plan that provides prescription drug benefits must accept the uniform prior authorization form when requiring prior authorization for prescription drug benefits.  If a health care service plan fails to utilize or accept said form, or fails to respond within two business days upon receipt from a prescribing provider, the request must be deemed to have been granted.

However, the law does not expand the list of drugs subject to prior authorization requirements or otherwise alter existing prior authorization criteria for prescription drugs.  It does not apply in the event that a physician or physician group has been delegated the financial risk for prescription drugs by a health plan and does not use a prior authorization process.  It also does not apply to a health plan if it owns and operates its pharmacies and does not use a prior authorization process for prescription drugs.  Further, the new law does not modify the prior authorization process for medical services and procedures other than prescription drugs.

Effective October 1, 2014, or January 1, 2015—depending on the type of health plan—every prescribing provider must use the form to request prior authorization for coverage of prescription drug benefits and health plans must accept it.

Reference materials:

"New Uniform Prescription Drug Prior Authorization Request Form and Notification Requirements for Health Plans in California" including background information, frequently asked questions, and form, courtesy of Johnson & Johnson Health Care Systems Inc.

Blue Shield of California Notice to Providers, September 12, 2014

HealthNet Provider Update July 15, 2014

Anthem Professional Bulletin, September, 2014

Prescription Drug Prior Authorization Request Form final rule adopted by the California Department of Managed Health Care