[California] New specialty pharmacy medical step therapy requirements
AI Summary
California Anthem has implemented new specialty pharmacy medical step therapy requirements, meaning patients must try and fail on less expensive specialty medications before accessing higher-tier specialty drugs. This will affect prior authorization processes and may delay patient access to certain specialty pharmaceuticals.
Action Required
Immediately: Billing and clinical staff must verify step therapy requirements before prescribing specialty medications for California Anthem patients. Update prior authorization workflows to include step therapy documentation. Providers should be prepared to document previous medication trials and failures when requesting specialty pharmacy approvals. Claims may be denied if step therapy requirements are not met.
Plan Types
Commercial
States
CA
Specialties
all-specialties