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New prescription drug prior authorization form required on Jan 1 for DMHC regulated products



December 11, 2014

On January 1, 2015, a new law will fully take effect that streamlines and standardizes the prior authorization process for prescription drugs. The 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, are 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 took effect on October 1, 2014.


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), which is also available on the payor websites, 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 (CMA) physician FAQ, “A Physician’s Guide to Implementation of SB 866: The new standardized prescription drug prior authorization form.” This document is available free to members.   


Practices that run into any problems with the form itself — integration into an EHR, submission of the form, multiple requests for medical records from payors, delays in processing, etc. — are encouraged to contact CMA at (888) 501-4911 or economicservices@cmadocs.org to share your experience.

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