Updates to prior authorization form for prescription medications and new timelines for response now in effect

September 08, 2017
Area(s) of Interest: Drug Prescribing/Dispensing Practice Management Patient Care 

On July 1, 2017, two new laws affecting the standardized prescription drug prior authorization form took effect.

SB 282 required the Department of Managed Health Care (DMHC) and the Department of Insurance to create a standard electronic prior authorization request form. A second related law (AB 374) required the agencies to include on the updated form the option for physicians to request an exception to the plan/insurer’s step therapy process. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form.

The form was updated in December 2016 and effective July 1, 2017, prescribers and payors are now required to use and accept this uniform prior authorization form, available on the DMHC website.

Step therapy exception requests are to be submitted in the same manner as a request for prior authorization for prescription drugs, and would require the plan or insurer to treat, and respond to, the request in the same manner as a request for prior authorization for prescription medications.

SB 282 also modified the timeframes in which plans/insurers are required to respond to the prior authorization/step therapy requests. Previously, plans/insurers were required to respond within two business days. SB 282 now requires plans/insurers to respond within 72 hours for nonurgent requests and within 24 hours for urgent requests. If a plan or insurer fails to respond within those timeframes, the request is deemed approved. The new law does not expand the list of medications that require a prior authorization.

Delegated physician groups do not have to use the standardized form if they have been delegated the financial risk for prescription drugs and do not use a prior authorization process.


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