Section 1367.241 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.241
. (a) Notwithstanding any other law, on and after January
1, 2013, a health care service plan that provides coverage for
prescription drugs shall accept only the prior authorization form
developed pursuant to subdivision (c), or an electronic prior
authorization process described in subdivision (e), when requiring
prior authorization for prescription drugs. This section does not
apply in the event that a physician or physician group has been
delegated the financial risk for prescription drugs by a health care
service plan and does not use a prior authorization process. This
section does not apply to a health care service plan, or to its
affiliated providers, if the health care service plan owns and
operates its pharmacies and does not use a prior authorization
process for prescription drugs.
(b) If a health care service plan or a contracted physician group
fails to respond within 72 hours for nonurgent requests, and within
24 hours if exigent circumstances exist, upon receipt of a completed
prior authorization request from a prescribing provider, the prior
authorization request shall be deemed to have been granted. The
requirements of this subdivision shall not apply to contracts entered
into pursuant to Chapter 7 (commencing with Section 14000), Chapter
8 (commencing with Section 14200), or Chapter 8.75 (commencing with
Section 14591) of Part 3 of Division 9 of the Welfare and
Institutions Code. Medi-Cal managed care health care service plans
that contract under those chapters shall not be required to maintain
an external exception request review as provided in Section 156.122
of Title 45 of the Code of Federal Regulations.
(c) On or before January 1, 2017, the department and the
Department of Insurance shall jointly develop a uniform prior
authorization form. Notwithstanding any other law, on and after July
1, 2017, or six months after the form is completed pursuant to this
section, whichever is later, every prescribing provider shall use
that uniform prior authorization form, or an electronic prior
authorization process described in subdivision (e), to request prior
authorization for coverage of prescription drugs and every health
care service plan shall accept that form or electronic process as
sufficient to request prior authorization for prescription drugs.
(d) The prior authorization form developed pursuant to subdivision
(c) shall meet the following criteria:
(1) The form shall not exceed two pages.
(2) The form shall be made electronically available by the
department and the health care service plan.
(3) The completed form may also be electronically submitted from
the prescribing provider to the health care service plan.
(4) The department and the Department of Insurance shall develop
the form with input from interested parties from at least one public
meeting.
(5) The department and the Department of Insurance, in development
of the standardized form, shall take into consideration the
following:
(A) Existing prior authorization forms established by the federal
Centers for Medicare and Medicaid Services and the State Department
of Health Care Services.
(B) National standards pertaining to electronic prior
authorization.
(e) A prescribing provider may use an electronic prior
authorization system utilizing the standardized form described in
subdivision (c) or 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.
(f) Subdivision (a) does not apply if any of the following occurs:
(1) A contracted physician group is delegated the financial risk
for prescription drugs by a health care service plan.
(2) A contracted physician group uses its own internal prior
authorization process rather than the health care service plan's
prior authorization process for plan enrollees.
(3) A contracted physician group is delegated a utilization
management function by the health care service plan concerning any
prescription drug, regardless of the delegation of financial risk.
(g) For prescription drugs, prior authorization requirements
described in subdivisions (c) and (e) apply regardless of how that
benefit is classified under the terms of the health plan's group or
individual contract.
(h) For purposes of this section:
(1) "Prescribing provider" shall include a provider authorized to
write a prescription, pursuant to subdivision (a) of Section 4040 of
the Business and Professions Code, to treat a medical condition of an
enrollee.
(2) "Exigent circumstances" exist when an enrollee is suffering
from a health condition that may seriously jeopardize the enrollee's
life, health, or ability to regain maximum function or when an
enrollee is undergoing a current course of treatment using a
nonformulary drug.
(3) "Completed prior authorization request" means a completed
uniform prior authorization form developed pursuant to subdivision
(c), or a completed request submitted using an electronic prior
authorization system described in subdivision (e), or, for contracted
physician groups described in subdivision (f), the process used by
the contracted physician group.