CA SB250

On or after January 1, 2024, health care service plans and health insurers cannot require prior authorization for services if they approved at least 90% of prior authorization requests from a health professional in the prior one-year period.

Physicians have the right to have prior authorization appeals conducted by a physician of the same or similar specialty, and plans/insurers cannot require an appeal to be filed before an independent medical review.

Health care providers involved in developing prior authorization criteria must include contracted physicians and health professionals who have experienced or are currently subject to utilization review or utilization management.

Brand name prescription drugs are included as "health care services" eligible for prior authorization exemptions until January 1, 2027; departments must report findings on this provision to the Legislature by July 1, 2026.

Plans and insurers can only rescind exemptions at the end of a 12-month period and cannot rescind outside that period unless the health professional committed fraud or pattern of abuse; a health professional can reapply for an exemption 12 months after a denial or rescission is affirmed.