Prior Authorization Form – New Law in California

Peter Forster Costs of Treatment, Policy

The pharmacist is on the phone getting a prior auth. Want to wait? It shouldn’t be more than an hour…

Prior authorization forms for medications, and the entire prior authorization process, can be a nightmare. In my experience, with at least one company, the rule seemed to be, if you filled out a form you were told that you needed to call to obtain the OK, and if you called you were told to fill out a form. It was not unusual for the entire process to take 50 plus minutes. And since the phones were only manned during the day, that meant blocking out an entire hour, at a cost of about 275$ to the practice. And even then the results were sometimes random.

A new California law (SB 866) requires all insurers, health plans 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 the insurance company fails to respond in that time frame the medication is automatically authorized.

The new law does not change the list of medications that require a prior authorization.

The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) worked together to develop the standardized authorization form the rules for using the forms.

Unfortunately, the timelines for implementation for the two agencies are different.

As a quick review, the Department of Managed Health Care is the agency that regulates all HMOs (Kaiser, etcetera), their contracting medical groups/IPAs and most Blue Cross and Blue Shield PPOs

For these plans, the effective date for implementation is  January 1, 2015.

The Department of Insurance regulates all other PPOs and the Blue Cross and Blue Shield Life & Health products. For these plans the law become effective on October 1, 2014.

And, of course, just to add even more confusion, if you work for a company that has offices out of the state, the insurance plan you have may be regulated by a different state.

This is confusing. But it is overall good news for most of us in California.

The California Medical Association provided the links to the insurance companies documents saying how they will be implementing the laws (some of them are even going to implement the law for all their plans immediately!).

You can click here to access the new form. The form (Form No. 61-211) should be available on insurance company websites.  The form can be submitted by mail, electronic transmission, fax, or web portal.

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.