Prescription drug coverage: dose adjustments

Patients with serious chronic conditions or cancer may avoid prior authorization and later utilization review when their provider needs a limited adjustment to an existing prescription. Plans and insurers must respond in writing within 72 hours.

What the law does ​

• Allows a treating in-network provider to request a dose or frequency adjustment without prior authorization or subsequent utilization management.
• Requires health plans and insurers to approve the request within 72 hours when the drug was previously covered for the patient's serious chronic condition or cancer treatment, remains prescribed for that treatment, is not an opioid or scheduled controlled substance, and has not already been adjusted more than twice without prior authorization.
• Excludes off-label uses unless they also meet existing coverage requirements for those uses.
• Excludes Medi-Cal managed care plans.

Who it affects ​

• Enrollees and insured people receiving previously covered drugs for serious chronic conditions or cancer treatment.
• Treating in-network providers requesting prescription dose or frequency changes.
• Health care service plans and health insurers.

Context ​

The streamlined process does not cover opioids, scheduled controlled substances, or more than two prior authorization-free adjustments.