November 12, 2014
A new law recently took effect that streamlines and standardizes the prior authorization process for prescription drugs for most patients with PPO products. The new law (SB 866) requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications.
The law also requires plans and insurers to make a determination on prescription drug prior authorization requests within two days of receipt. If they fail to do so, the requests will be deemed authorized. The new law does not expand the list of medications that require a prior authorization.
The requirement for HMO products, including Anthem Blue Cross and Blue Shield of California, becomes effective on January 1, 2015. The regulation for Department of Insurance-regulated products, including all other PPOs and Blue Cross and Blue Shield Life & Health products, became effective on October 1, 2014. However, in an effort to avoid confusion for practices, many plans/insurers implemented the new form across most, if not all, of their product lines on October 1.
The California Medical Association (CMA) is interested in hearing from practices that have experienced difficulties with the new form. If your practice has run into any problems with the form itself, integration into your EHR, submission of the form to the payor, multiple requests for medical records from the payor, delays in processing by the payor, etc., please contact CMA at (916) 551-2061 or firstname.lastname@example.org to share your experience.
For information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the CMA physician FAQ, “A Physician’s Guide to Implementation of SB866: The new standardized prescription drug prior authorization form.” This document is available free to members.