Prior Authorization Requirements

This bill would remove barriers confronting a patient’s access to necessary medications.

Currently, health plans may require subscribers to submit certain prescriptions for approval before they are covered, through a process known as prior authorization. While this is a necessary process for several medications, it has become increasingly used for medications that do not need to go through the process. This added level of bureaucracy takes time for physicians and can be confusing, as they are unaware which drugs are covered. Additionally, these formularies (which are detailed lists of covered medications) are different across all health plans, and plans can eliminate and add drugs to a formulary at any time.

This bill would make the process more standardized and less time-consuming for prescribers through several modifications to prior authorization. It shortens the time available to process prior authorization requests and adds a process to report which requests were approved and denied. The bill also requires a health plan to release its formulary prior to the renewal period and prohibits removing drugs that increase costs for patients, unless they also add a similar drug that will lower the cost. If the formulary does change, the health plan would have to establish a transition period to prevent coverage gaps.

To oversee this process, the bill would create an advisory council within the Department of Health to provide guidance in the changes and trends that occur within prescription coverage and formularies. Supporters state these changes place the patient’s care first and guarantee they get the care they deserve.

STATUS: The bill is in the Finance Committee. (S.F. 934)

NEXT IN HHSH: CARE Act (Caregiver Advise, Record, Enable)

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