September 15, 2014
Over the next several months, a new law will take effect that streamlines and standardizes the prior authorization process for prescription drugs. 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, and 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 Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations. The two agencies, however, will be enforcing the regulations on different timetables.
The regulation for DMHC regulated products, which includes all HMOs, their contracting medical groups/IPAs and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products become effective on October 1, 2014.
The lack of synchronicity in the effective dates has the potential to cause confusion for practices, particularly those who treat patients with Anthem Blue Cross PPO or Blue Shield of California PPO products, as it can be difficult to determine whether the patient has a DOI regulated product, a DMHC regulated product or a product that is regulated out-of-state (i.e., Blue Card product).
However, in an effort to avoid confusion for practices, some plans/insurers are implementing the new form across most, if not all, of their product lines on October 1. There are exceptions, however, so practices are encouraged to review the payor notices and to call payors with any specific questions they may have.
Practices using EHR systems that incorporate plan/insurer and medication specific forms for prescription drug prior authorizations are encouraged to contact the vendors about how they are accommodating this change.
Click here to access the new form. The form (Form No. 61-211) will also be available on the payor websites by October 1 and can be submitted via paper, electronic transmission, fax, web portal or another mutually agreeable method.
For more information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the California Medical Association 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.