SB 282, as amended, Hernandez. Health care coverage: prescription drugs.
Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law provides for the regulation of health insurers by the Department of Insurance. Commonly referred to as utilization review, existing law governs the procedures that apply to every health care service plan and health insurer that prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based on medical necessity, requests by providers prior to, retrospectively, or concurrent with, the provision of health care services to enrollees or insureds, as specified.
Existing law requires the Department of Managed Health Care and the Department of Insurance to jointly develop a uniform prior authorization form for prescription drug benefits on or before July 1, 2012, and requires, 6 months after the form is developed, every prescribing provider, when requesting prior authorization for prescription drug benefits, to submit the request to the health care service plan or health insurer using the uniform form, and requires those plans and insurers to accept only the uniform form. Existing law authorizes a prescribing provider to submit the prior authorization form electronically to the plan or insurer, and, if the plan or insurer fails to respond to a request within 2 business days, the request is deemed granted. Existing law also requires health care service plans to maintain a process by which prescribing providers may obtain authorization for a medically necessary nonformulary prescription drug.
This bill would authorize the prescribing provider to additionally use an electronic process developed specifically for transmitting prior authorization information that meets the National Council for Prescription Drug Programs’ SCRIPT standard for electronic prior authorization transactions. The bill would require the departments to develop the uniform prior authorization form on or before January 1, 2017, and would require prescribing providers to use, and health care service plans and health insurers to accept, only those forms on and after July 1, 2017, or 6 months after the form is developed, whichever is later. This bill would deem a prior authorization request to be granted if the plan or insurer fails to respond within 72 hours for nonurgent requests, and within 24 hours when exigent circumstances exist.
This bill would specify that the provisions described above relating to prior authorization for prescription drugs do not apply if a contracted
begin delete networkend delete
physician group is delegated the financial risk for the prescription drugs by a health care service plan or health insurer, if a contracted begin delete networkend delete physician group uses its own internal prior authorization process rather than the health care service plan’s or the health insurer’s prior authorization process for its enrollees or insureds, or if a contracted begin delete networkend delete physician group is delegated a utilization management function by the health care service plan or the health insurer concerning any prescription drug, regardless of the delegation of financial risk.
Existing law requires health care service plans to establish a grievance process approved by the Department of Managed Health Care.
This bill would
begin delete requireend delete the grievance process established by a health care service plan to comply with specified federal regulations.
Because a willful violation of the bill’s requirements relative to health care service plans would be a crime, this bill would impose a state-mandated local program.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: yes.
The people of the State of California do enact as follows:
Section 1367.24 of the Health and Safety Code
2 is amended to read:
(a) Every health care service plan that provides
4prescription drug benefits shall maintain an expeditious process
5by which prescribing providers may obtain authorization for a
6medically necessary nonformulary prescription drug. On or before
7July 1, 1999, every health care service plan that provides
8prescription drug benefits shall file with the department a
9description of its process, including timelines, for responding to
10authorization requests for nonformulary drugs. Any changes to
11this process shall be filed with the department pursuant to Section
121352. Each plan shall provide a written description of its most
13current process, including timelines, to its prescribing providers.
14For purposes of this section, a prescribing provider shall include
15a provider authorized to write a prescription, pursuant to
16subdivision (a) of Section 4040 of the Business and Professions
17Code, to treat a medical condition of an enrollee.
18(b) Any plan that disapproves a request made pursuant to
19subdivision (a) by a prescribing provider to obtain authorization
20for a nonformulary drug shall provide the reasons for the
21disapproval in a notice provided to the enrollee. The notice shall
22indicate that the enrollee may file a grievance
begin delete seeking an external with the plan if the enrollee objects to
23exception request reviewend delete
24the disapproval, including any alternative drug or treatment offered
25by the plan. The notice shall comply with subdivision (b) of Section
begin delete26 1368.02, and
the health care service plan shall comply with
27subdivision (l) of this section.end delete
5(c) The process described in subdivision (a) by which
6prescribing providers may obtain authorization for medically
7necessary nonformulary drugs shall not apply to a nonformulary
8drug that has been prescribed for an enrollee in conformance with
9the provisions of Section 1367.22.
10(d) The process described in subdivision (a) by which enrollees
11may obtain medically necessary nonformulary drugs, including
12specified timelines for responding to prescribing provider
13authorization requests, shall be described in evidence of coverage
14and disclosure forms, as required by subdivision (a) of Section
151363, issued on or after July 1, 1999.
16(e) Every health care service plan that provides prescription
17drug benefits shall maintain, as part of its books and records under
18Section 1381, all of the following information, which shall be
19made available to the director upon request:
20(1) The complete drug formulary or formularies of the plan, if
21the plan maintains a formulary, including a list of the prescription
22drugs on the formulary of the plan by major therapeutic category
23with an indication of whether any drugs are preferred over other
25(2) Records developed by the pharmacy and therapeutic
26committee of the plan, or by others responsible for developing,
27modifying, and overseeing formularies, including medical groups,
28individual practice associations, and contracting pharmaceutical
29benefit management companies, used to guide the drugs prescribed
30for the enrollees of the plan, that fully describe the reasoning
31behind formulary decisions.
32(3) Any plan arrangements with prescribing providers, medical
33groups, individual practice associations, pharmacists, contracting
34pharmaceutical benefit management companies, or other entities
35that are associated with activities of the plan to encourage
36formulary compliance or otherwise manage prescription drug
38(f) If a plan provides prescription drug benefits, the department
39shall, as part of its periodic onsite medical survey of each plan
40undertaken pursuant to Section 1380, review the performance of
P5 1the plan in providing those benefits, including, but not limited to,
2a review of the procedures and information maintained pursuant
3to this section, and describe the performance of the plan as part of
4its report issued pursuant to Section 1380.
5(g) The director shall not publicly disclose any information
6reviewed pursuant to this section that is determined by the director
7to be confidential pursuant to state law.
8(h) For purposes of this section, “authorization” means approval
9by the health care service plan to provide payment for the
11(i) Nonformulary prescription drugs shall include any drug for
12which an enrollee’s copayment or out-of-pocket costs are different
13than the copayment for a formulary prescription drug, except as
14otherwise provided by law or regulation or in cases in which the
15drug has been excluded in the plan contract pursuant to Section
17(j) Nothing in this section shall be construed to restrict or impair
18the application of any other provision of this chapter, including,
19but not limited to, Section 1367, which includes among its
20requirements that a health care service plan furnish services in a
21manner providing continuity of care and demonstrate that medical
22decisions are rendered by qualified medical providers unhindered
23by fiscal and administrative management.
begin deleteA end deletehealth care service plan’s process described in
26subdivision (a) shall comply with
28 subdivision (c) of Section 156.122 of Title 45 of the Code of
32(l) A health care service plan shall maintain a process for an
33external exception request review that complies with subdivision
34(c) of Section 156.122 of Title 45 of the Code of Federal
3(m) Nothing in this section shall be construed to affect an
4enrollee’s or subscriber’s eligibility to submit a grievance to the
5department for review under Section 1368 or to apply to the
6department for an independent medical review under Section
71370.4, or Article 5.55 (commencing with Section 1374.30) of
Section 1367.241 of the Health and Safety Code is
10amended to read:
(a) Notwithstanding any other law, on and after
12January 1, 2013, a health care service plan that provides coverage
13for prescription drugs shall accept only the prior authorization
14form developed pursuant to subdivision (c), or an electronic prior
15authorization process described in subdivision (e), when requiring
16prior authorization for prescription drugs. This section does not
17apply in the event that a physician or physician group has been
18delegated the financial risk for prescription drugs by a health care
19service plan and does not use a prior authorization process. This
20section does not apply to a health care service plan, or to its
21affiliated providers, if the health care service plan owns and
22operates its pharmacies and does not use a prior authorization
23process for prescription drugs.
24(b) If a health care service plan
begin delete to utilize or accept the prior authorization form, or failsend delete to
26respond within 72 hours for nonurgent requests, and within 24
27hours if exigent circumstances exist, upon receipt of a completed
28prior authorization request from a prescribing provider,
begin delete pursuant the prior authorization request
29to the submission of the prior authorization form developed as
30described in subdivision (c), or an electronic prior authorization
31process described in subdivision (e),end delete
32shall be deemed to have been granted. The requirements of this
33subdivision shall not apply to contracts entered into pursuant to
begin delete Article 2.7 (commencing with Section 14087.3), Article 2.8 Chapter 8 (commencing with Section
35(commencing with Section 14087.5), Article 2.81 (commencing
36with Section 14087.96), or Article 2.91 (commencing with Section
3714089) of Chapter 7 of, orend delete
begin delete 14200) of,end delete Part 3 of
40Division 9 of the Welfare and Institutions Code.
5(c) On or before January 1, 2017, the department and the
6Department of Insurance shall jointly develop a uniform prior
7authorization form. Notwithstanding any other law, on and after
8July 1, 2017, or six months after the form is completed pursuant
9to this section, whichever is later, every prescribing provider shall
10use that uniform prior authorization form, or an electronic prior
11authorization process described in subdivision (e), to request prior
12authorization for coverage of prescription drugs and every health
13care service plan shall accept that form as
14sufficient to request prior authorization for prescription drugs.
15(d) The prior authorization form developed pursuant to
16subdivision (c) shall meet the following criteria:
17(1) The form shall not exceed two pages.
18(2) The form shall be made electronically available by the
19department and the health care service plan.
20(3) The completed form may also be electronically submitted
21from the prescribing provider to the health care service plan.
22(4) The department and the Department of Insurance shall
23develop the form with input from interested parties from at least
24one public meeting.
25(5) The department and the Department of Insurance, in
26development of the standardized form, shall take into consideration
28(A) Existing prior authorization forms established by the federal
29Centers for Medicare and Medicaid Services and the State
30Department of Health Care Services.
31(B) National standards pertaining to electronic prior
33(e) A prescribing provider may use an electronic prior
34authorization system utilizing the standardized form described in
35subdivision (c) or an electronic process developed specifically for
36transmitting prior authorization information that meets the National
37Council for Prescription Drug Programs’ SCRIPT standard for
38electronic prior authorization transactions.
39(f) Subdivision (a) does not apply if any of the following occurs:
P8 1(1) A contracted
begin delete networkend delete
physician group is delegated the
2financial risk for prescription drugs by a health care service plan.
3(2) A contracted
begin delete networkend delete physician group uses its own internal
4prior authorization process rather than the health care service plan’s
5prior authorization process for plan enrollees.
6(3) A contracted
begin delete networkend delete physician group is delegated a
7utilization management function by the health care service plan
8concerning any prescription drug, regardless of the delegation of
begin deletePrior end deleteauthorization
begin delete for prescription drugs under this
13classified under the terms of the health plan’s
begin delete subscriberend delete or
begin delete providerend delete contract.
15(h) For purposes of this section:
16(1) “Prescribing provider” shall include a provider authorized
17to write a prescription, pursuant to subdivision (a) of Section 4040
18of the Business and Professions Code, to treat a medical condition
19of an enrollee.
20(2) “Exigent circumstances” exist when an enrollee is suffering
21from a health condition that may seriously jeopardize the enrollee’s
22life, health, or ability to regain maximum function or when an
23enrollee is undergoing a current course of treatment using a
Section 1368 of the Health and Safety Code is amended
(a) Every plan shall do all of the following:
34(1) Establish and maintain a grievance system approved by the
35department under which enrollees may submit their grievances to
36the plan. Each system shall provide reasonable procedures in
37accordance with department regulations that shall ensure adequate
38consideration of enrollee grievances and rectification when
P9 1(2) Inform its subscribers and enrollees upon enrollment in the
2plan and annually thereafter of the procedure for processing and
3resolving grievances. The information shall include the location
4and telephone number where grievances may be submitted.
5(3) Provide forms for
grievances to be given to subscribers and
6enrollees who wish to register written grievances. The forms used
7by plans licensed pursuant to Section 1353 shall be approved by
8the director in advance as to format.
9(4) (A) Provide for a written acknowledgment within five
10calendar days of the receipt of a grievance, except as noted in
11subparagraph (B). The acknowledgment shall advise the
12complainant of the following:
13(i) That the grievance has been received.
14(ii) The date of receipt.
15(iii) The name of the plan representative and the telephone
16number and address of the plan representative who may be
17contacted about the grievance.
18(B) (i) Grievances
received by telephone, by facsimile, by
19email, or online through the plan’s Internet Web site pursuant to
20Section 1368.015, that are not coverage disputes, disputed health
21care services involving medical necessity, or experimental or
22investigational treatment and that are resolved by the next business
23day following receipt are exempt from the requirements of
24subparagraph (A) and paragraph (5). The plan shall maintain a log
25of all these grievances. The log shall be periodically reviewed by
26the plan and shall include the following information for each
28(I) The date of the call.
29(II) The name of the complainant.
30(III) The complainant’s member identification number.
31(IV) The nature of the grievance.
32(V) The nature of the resolution.
33(VI) The name of the plan representative who took the call and
34resolved the grievance.
begin deleteA end deletehealth care service plan’s response to
37grievances subject to Section 1367.24 shall also comply with
38subdivision (c) of Section 156.122 of Title 45 of the Code of
6(5) Provide subscribers and enrollees with written responses to
7grievances, with a clear and concise explanation of the reasons for
8the plan’s response. For grievances involving the delay, denial, or
9modification of health care services, the plan response shall
10describe the criteria used and the clinical reasons for its decision,
11including all criteria and clinical reasons related to medical
12necessity. If a plan, or one of its contracting providers, issues a
13decision delaying, denying, or modifying health care services based
14in whole or in part on a finding that the proposed health care
15services are not a covered benefit under the contract that applies
16to the enrollee, the decision shall clearly specify the provisions in
17the contract that exclude that coverage.
18(6) For grievances involving the cancellation, rescission, or
19nonrenewal of a health care service plan contract, the health care
20service plan shall continue to provide coverage to the enrollee or
21subscriber under the terms of the health care service plan contract
22until a final determination of the enrollee’s or subscriber’s request
23for review has been made by the health care service plan or the
24director pursuant to Section 1365 and this section. This paragraph
25shall not apply if the health care service plan cancels or fails to
26renew the enrollee’s or subscriber’s health care service plan
27contract for nonpayment of premiums pursuant to paragraph (1)
28of subdivision (a) of Section 1365.
29(7) Keep in its files all copies of grievances, and the responses
30thereto, for a period of five years.
31(b) (1) (A) After either completing the grievance process
32described in subdivision (a), or participating in the process for at
33least 30 days, a subscriber or enrollee may submit the grievance
34to the department for review. In any case determined by the
35department to be a case involving an imminent and serious threat
36to the health of the patient, including, but not limited to, severe
37pain, the potential loss of life, limb, or major bodily function,
38cancellations, rescissions, or the nonrenewal of a health care service
39plan contract, or in any other case where the department determines
40that an earlier review is warranted, a subscriber or enrollee shall
P11 1not be required to complete the grievance process or to participate
2in the process for at least 30 days before submitting a grievance
3to the department for review.
4(B) A grievance may be
submitted to the department for review
5and resolution prior to any arbitration.
6(C) Notwithstanding subparagraphs (A) and (B), the department
7may refer any grievance that does not pertain to compliance with
8this chapter to the State Department of Public Health, the California
9Department of Aging, the federal Health Care Financing
10Administration, or any other appropriate governmental entity for
11investigation and resolution.
12(2) If the subscriber or enrollee is a minor, or is incompetent or
13incapacitated, the parent, guardian, conservator, relative, or other
14designee of the subscriber or enrollee, as appropriate, may submit
15the grievance to the department as the agent of the subscriber or
16enrollee. Further, a provider may join with, or otherwise assist, a
17subscriber or enrollee, or the agent, to submit the grievance to the
18department. In addition, following submission of the grievance to
19the department, the subscriber or enrollee, or the agent, may
20authorize the provider to assist, including advocating on behalf of
21the subscriber or enrollee. For purposes of this section, a “relative”
22includes the parent, stepparent, spouse, adult son or daughter,
23grandparent, brother, sister, uncle, or aunt of the subscriber or
25(3) The department shall review the written documents submitted
26with the subscriber’s or the enrollee’s request for review, or
27submitted by the agent on behalf of the subscriber or enrollee. The
28department may ask for additional information, and may hold an
29informal meeting with the involved parties, including providers
30who have joined in submitting the grievance or who are otherwise
31assisting or advocating on behalf of the subscriber or enrollee. If
32after reviewing the record, the department concludes that the
33grievance, in whole or in part, is eligible for review under the
34independent medical review system established pursuant to Article
355.55 (commencing with Section 1374.30), the department shall
36immediately notify the subscriber or enrollee, or agent, of that
37option and shall, if requested orally or in writing, assist the
38subscriber or enrollee in participating in the independent medical
P12 1(4) If after reviewing the record of a grievance, the department
2concludes that a health care service eligible for coverage and
3payment under a health care service plan contract has been delayed,
4denied, or modified by a plan, or by one of its contracting
5providers, in whole or in part due to a determination that the service
6is not medically necessary, and that determination was not
7communicated to the enrollee in writing along with a notice of the
8enrollee’s potential right to participate in the independent medical
9review system, as required by this chapter, the director shall, by
10order, assess administrative penalties. A proceeding for the issuance
11of an order assessing administrative penalties shall be subject to
12appropriate notice of, and the opportunity for, a hearing with regard
13to the person affected in accordance with Section 1397. The
14administrative penalties shall not be deemed an exclusive remedy
15available to the director. These penalties shall be paid to the
16Managed Care Administrative Fines and Penalties Fund and shall
17be used for the purposes specified in Section 1341.45.
18(5) The department shall send a written notice of the final
19disposition of the grievance, and the reasons therefor, to the
20subscriber or enrollee, the agent, to any provider that has joined
21with or is otherwise assisting the subscriber or enrollee, and to the
22plan, within 30 calendar days of receipt of the request for review
23unless the director, in his or her discretion, determines that
24additional time is reasonably necessary to fully and fairly evaluate
25the relevant grievance. In any case not eligible for the independent
26medical review system established pursuant to Article 5.55
27(commencing with Section 1374.30), the department’s written
28notice shall include, at a minimum, the following:
29(A) A summary of its findings and the reasons why the
30department found the plan to be, or not to be, in compliance with
31any applicable laws, regulations, or orders of the director.
32(B) A discussion of the department’s contact with any medical
33provider, or any other independent expert relied on by the
34department, along with a summary of the views and qualifications
35of that provider or expert.
36(C) If the enrollee’s grievance is sustained in whole or in part,
37information about any corrective action taken.
38(6) In any department review of a grievance
involving a disputed
39health care service, as defined in subdivision (b) of Section
401374.30, that is not eligible for the independent medical review
P13 1system established pursuant to Article 5.55 (commencing with
2Section 1374.30), in which the department finds that the plan has
3delayed, denied, or modified health care services that are medically
4necessary, based on the specific medical circumstances of the
5enrollee, and those services are a covered benefit under the terms
6and conditions of the health care service plan contract, the
7department’s written notice shall do either of the following:
8(A) Order the plan to promptly offer and provide those health
9care services to the enrollee.
10(B) Order the plan to promptly reimburse the enrollee for any
11reasonable costs associated with urgent care or emergency services,
12or other extraordinary and compelling health care services, when
13the department finds that the enrollee’s decision to secure those
14services outside of the plan network was reasonable under the
16The department’s order shall be binding on the plan.
17(7) Distribution of the written notice shall not be deemed a
18waiver of any exemption or privilege under existing law, including,
19but not limited to, Section 6254.5 of the Government Code, for
20any information in connection with and including the written
21notice, nor shall any person employed or in any way retained by
22the department be required to testify as to that information or
24(8) The director shall establish and maintain a system of aging
25of grievances that are pending and unresolved for 30 days or more
26that shall include a brief explanation of the reasons each grievance
27is pending and unresolved for 30 days or more.
28(9) A subscriber or enrollee, or the agent acting on behalf of a
29subscriber or enrollee, may also request voluntary mediation with
30the plan prior to exercising the right to submit a grievance to the
31department. The use of mediation services shall not preclude the
32right to submit a grievance to the department upon completion of
33mediation. In order to initiate mediation, the subscriber or enrollee,
34or the agent acting on behalf of the subscriber or enrollee, and the
35plan shall voluntarily agree to mediation. Expenses for mediation
36shall be borne equally by both sides. The department shall have
37no administrative or enforcement responsibilities in connection
38with the voluntary mediation process authorized by this paragraph.
39(c) The plan’s grievance system shall include a system of aging
40 of grievances that are pending and unresolved for 30 days or more.
P14 1The plan shall provide a quarterly report to the director of
2grievances pending and unresolved for 30 or more days with
3separate categories of grievances for Medicare enrollees and
4Medi-Cal enrollees. The plan shall include with the report a brief
5explanation of the reasons each grievance is pending and
6unresolved for 30 days or more. The plan may include the
7following statement in the quarterly report that is made available
8to the public by the director:
10“Under Medicare and Medi-Cal law, Medicare enrollees and
11Medi-Cal enrollees each have separate avenues of appeal that
12are not available to other enrollees. Therefore, grievances
13pending and unresolved may reflect enrollees pursuing their
14Medicare or Medi-Cal appeal rights.”
16If requested by a plan, the director shall include this statement in
17a written report made available to the public and prepared by the
18director that describes or compares grievances that are pending
19and unresolved with the plan for 30 days or more. Additionally,
20the director shall, if requested by a plan, append to that written
21report a brief explanation, provided in writing by the plan, of the
22reasons why grievances described in that written report are pending
23and unresolved for 30 days or more. The director shall not be
24required to include a statement or append a brief explanation to a
25written report that the director is required to prepare under this
26chapter, including Sections 1380 and 1397.5.
27(d) Subject to subparagraph (C) of paragraph (1) of subdivision
28(b), the grievance or resolution procedures authorized by this
29section shall be in addition to any other procedures that may be
30available to any person, and failure to pursue, exhaust, or engage
31in the procedures described in this section shall not preclude the
32use of any other remedy provided by law.
33(e) Nothing in this section shall be construed to allow the
34submission to the department of any provider grievance under this
35section. However, as part of a provider’s duty to advocate for
36medically appropriate health care for his or her patients pursuant
37to Sections 510 and 2056 of the Business and Professions Code,
38nothing in this subdivision shall be construed to prohibit a provider
39from contacting and informing the department about any concerns
P15 1he or she has regarding compliance with or enforcement of this
3(f) To the extent required by Section 2719 of the federal Public
4Health Service Act (42 U.S.C. Sec. 300gg-19) and any subsequent
5rules or regulations, there shall be an independent external review
6pursuant to the standards required by the United States Secretary
7of Health and Human Services of a health care service plan’s
8cancellation, rescission, or nonrenewal of an enrollee’s or
Section 1368.01 of the Health and Safety Code is
11amended to read:
(a) The grievance system shall require the plan to
13resolve grievances within 30 days, except as provided in
15(b) The grievance system shall include a requirement for
16expedited plan review of grievances for cases involving an
17imminent and serious threat to the health of the patient, including,
18but not limited to, severe pain, potential loss of life, limb, or major
19bodily function. When the plan has notice of a case requiring
20expedited review, the grievance system shall require the plan to
21immediately inform enrollees and subscribers in writing of their
22right to notify the department of the grievance. The grievance
23system shall also require the plan to provide enrollees, subscribers,
24and the department with a written statement on the disposition or
25pending status of the grievance no later than three days from receipt
26of the grievance, except as provided in subdivision (c). Paragraph
27(4) of subdivision (a) of Section 1368 shall not apply to grievances
28handled pursuant to this section.
29(c) A health care service plan that provides coverage for outpatient
31prescription drugs shall comply with subdivision (c) of Section
32156.122 of Title 45 of the Code of Federal Regulations.
Section 10123.191 of the Insurance Code is amended
(a) Notwithstanding any other law, on and after
2January 1, 2013, a health insurer that provides coverage for
3prescription drugs shall utilize and accept only the prior
4authorization form developed pursuant to subdivision (c), or an
5electronic prior authorization process described in subdivision (e),
6when requiring prior authorization for prescription drugs.
7(b) If a health insurer fails
begin delete to to respond
8utilize or accept the prior authorization form, or failsend delete
9within 72 hours for nonurgent requests, and within 24 hours if
10exigent circumstances exist, upon receipt of a completed prior
11authorization request from a prescribing provider,
begin delete pursuant to the the prior authorization request shall
12submission of the prior authorization form developed as described
13in subdivision (c), or an electronic prior authorization process
14described in subdivision (e),end delete
15be deemed to have been granted.
begin delete The requirements of this
16subdivision shall not apply to contracts entered into pursuant to
17Article 2.7 (commencing with Section 14087.3), Article 2.8
18(commencing with Section 14087.5), Article 2.81 (commencing
19with Section 14087.96), or Article 2.91 (commencing with Section
2014089) of Chapter 7 of, or Chapter 8 (commencing with Section
2114200) of, Part 3 of Division 9 of the Welfare and Institutions
23(c) On or before January 1, 2017, the department and the
24Department of Managed Health Care shall jointly develop a
25uniform prior authorization form. Notwithstanding any other law,
26on and after July 1, 2017, or six months after the form is completed
27pursuant to this section, whichever is later, every prescribing
28provider shall use that uniform prior authorization form, or an
29electronic prior authorization process described in subdivision (e),
30to request prior authorization for coverage of prescription drugs
31and every health insurer shall accept that form
32 as sufficient to request prior authorization for prescription drugs.
33(d) The prior
authorization form developed pursuant to
34subdivision (c) shall meet the following criteria:
35(1) The form shall not exceed two pages.
36(2) The form shall be made electronically available by the
37department and the health insurer.
38(3) The completed form may also be electronically submitted
39from the prescribing provider to the health insurer.
P17 1(4) The department and the Department of Managed Health
2Care shall develop the form with input from interested parties from
3at least one public meeting.
4(5) The department and the Department of Managed Health
5Care, in development of the standardized form, shall take into
6consideration the following:
7(A) Existing prior authorization forms established by the federal
8Centers for Medicare and Medicaid Services and the State
9Department of Health Care Services.
10(B) National standards pertaining to electronic prior
12(e) A prescribing provider may use an electronic prior
13authorization system utilizing the standardized form described in
14subdivision (c) or an electronic process developed specifically for
15transmitting prior authorization information that meets the National
16Council for Prescription Drug Programs’ SCRIPT standard for
17electronic prior authorization transactions.
18(f) Subdivision (a) does not apply if any of the following occurs:
19(1) A contracted
begin delete networkend delete
physician group is delegated the
20financial risk for the pharmacy or medical drug benefit by a health
22(2) A contracted
begin delete networkend delete physician group uses its own internal
23prior authorization process rather than the health insurer’s prior
24authorization process for the health insurer’s insureds.
25(3) A contracted
begin delete networkend delete
physician group is delegated a
26utilization management function by the health insurer concerning
27any prescription drug, regardless of the delegation of financial
begin deletePrior end delete authorization
begin delete for prescription drugs under this sectionend delete apply regardless of how that benefit is
32classified under the terms of the health insurer’s
begin delete policyholder or
33provider contract.end delete
P18 1(h)end delete
2 For purposes of this section:
3(1) “Prescribing provider” shall include a provider authorized
4to write a prescription, pursuant to subdivision (a) of Section 4040
5of the Business and Professions Code, to treat a medical condition
6of an insured.
7(2) “Exigent circumstances” exist when an insured is suffering
8from a health condition that may seriously jeopardize the insured’s
9life, health, or ability to regain maximum function or when an
10insured is undergoing a current course of treatment using a
No reimbursement is required by this act pursuant to
19Section 6 of Article XIII B of the California Constitution because
20the only costs that may be incurred by a local agency or school
21district will be incurred because this act creates a new crime or
22infraction, eliminates a crime or infraction, or changes the penalty
23for a crime or infraction, within the meaning of Section 17556 of
24the Government Code, or changes the definition of a crime within
25the meaning of Section 6 of Article XIII B of the California