AB 1880 Summary

• Requires health care service plans and health insurers to have appeals of prior authorization and step therapy denials reviewed by a clinical peer with no involvement in the initial coverage determination.

• Defines "clinical peer" as a physician or health professional with an unrestricted license whose practice is in the same or similar specialty as the condition or treatment under review.

• Mandates health care service plans and insurers maintain detailed information for at least 10 years regarding exception requests, step therapy requests, and prior authorization requests, including approval rates, denial reasons, and appeal outcomes, available to regulators upon request.

• Contracts between health care service plans and utilization review organizations must include compliance requirements for these provisions, effective January 1, 2022.

• Applies similar step therapy exception criteria to both health service plans and health insurers, allowing exceptions when drugs are contraindicated, ineffective, previously tried unsuccessfully, or clinically inappropriate for the patient's condition.