CommercialPrior AuthHigh impact
22-264m Apply New Processes for Prescription Prior Authorization and Step Therapy, and Ensure PrEP Coverage
Health Net·CA·Prior Authorization
We identified it
Jun 20, 2026
Summary
AB 347 requires participating physician groups (PPGs) to implement new prescription prior authorization and step therapy processes for self-injectable drugs, preventing automatic denials without medical documentation review. Additionally, Bulletin 2021-10 mandates coverage of HIV PrEP drugs (including injectable Apretude) as preventive care without cost sharing for commercial plans.
Action Required
Immediately: Update prior authorization workflows to ensure denials for nonformulary drugs and step therapy exceptions are based on medical necessity documentation rather than automatic failure-to-try requirements. Billing team must modify PA processing to include clinical documentation review before denial. Update formulary systems to list PrEP drugs (Truvada generic, Descovy, Apretude) as preventive medications with zero copay for commercial plans. Train staff on new appeal notification requirements for step therapy denials.