A new law took effect Jan. 1, 2016, that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 for urgent requests. The law (SB 282) deems such requests to be granted if the payor fails to respond within these timeframes. A previous law (SB 866) had required a determination within two business days or the request was deemed approved.

SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than Jan. 1, 2017. Prescribers and payors will be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or 6 months after the form is developed, whichever is later. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form.

A second and related law (AB 374) requires that prior authorization for prescription drug step therapy override requests be submitted in the same manner—and using the same electronic form, when available—as a prescription drug prior authorization requests. Plans and insurer must also respond to such requests within the timeframes set forth in SB 282.

Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmadocs.org.