Provider Alerts - September 7, 2017

New Pharmacy Prior Authorization Form – Effective 09/21/2017

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Date: September 7, 2017
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers and Pharmacies
From: Health Plan of San Joaquin Pharmacy Department
Subject: New Pharmacy Prior Authorization Form – Effective 09/21/2017
Business: Medi-Cal

Effective 09/21/2017

Starting September 21, 2017, HPSJ will ONLY accept the state-mandated prior authorization form (Form 61-211, revised 12/16) pursuant to California Senate Bill (SB) 282.

This law requires all faxed prior authorizations for prescription medications to be submitted on the Department of Managed Health Care (DMHC)’s mandated state-wide prior authorization form. The law does not change the drugs requiring prior authorization by Health Plan of San Joaquin OR the process and/or fax numbers for Prior Authorization submission.

EFFECTIVE SEPTEMBER 21, 2017-

**PRIOR AUTHORIZATION REQUESTS SUBMITTED ON OLDER FORMS WILL NOT BE ACCEPTED**

Changes to the DMHC-mandated form include –

  • An option for requesting prior authorization OR step-therapy exception.
  • ICD-10 Diagnosis code(s) section.
  • Added checkbox for priority selection.
    • Options include Non-Urgent or Exigent Circumstances.
    • “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 non-formulary drug.” (KKA Section 1367.241(h)(2); Ins. Code Section 10123.191 (j)(2).)

The Form is available on our website: www.hpsj.com/forms‐documents

  • On the Provider page under Pharmacy Tools & Resources
  • The PDF file name is “Medication Prior Authorization Form”

Please fax the completed form to the number below: Health Plan of San Joaquin
Pharmacy Prior Authorization
FAX: (209) 762-4704


Health Plan of San Joaquin is dedicated to providing all members the best health care available in the most effective and efficient manner.
Thank you for your cooperation with this new state-mandated requirement and for your continued partnership with Health Plan of San Joaquin.

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