Medi-Cal Rx pharmacy benefit transition (Medi-Cal Rx)
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Transition of Medi-Cal pharmacy services billed on pharmacy claims from managed care and legacy FFS intermediaries to DHCS's Medi-Cal Rx contractor (Magellan) effective January 1, 2021; affects providers, pharmacies, prescribers, and Medi-Cal beneficiaries.
DHCS will transition all Medi-Cal pharmacy services billed on pharmacy claims from managed care and existing FFS intermediaries to a new vendor, Magellan, under a program called Medi-Cal Rx effective January 1, 2021.
A transition policy includes grandfathering of existing prior authorizations and a 180-day period without PA requirements for existing prescriptions.
Medi-Cal Rx scope excludes pharmacy services billed on medical (professional) or institutional claims and does not change Medicare Part D coverage for dual eligibles.
Members should present their Medi-Cal Benefits Identification Card (BIC) at pharmacies beginning January 1, 2021; a pharmacy locator and customer service line are available.
Medi-Cal Rx Coverage and Scope
Medi-Cal Rx coverage criteria
Covered when the following scope and rules are met:
See Medi-Cal Rx scope and effective date.
Pharmacy services billed on medical/institutional claims are excluded from Medi-Cal Rx.
ALL of the following
Transition PA provisions
- Existing prior authorizations previously approved by managed care plans or fee-for-service intermediaries may be grandfathered through their stated duration.
- DHCS will not require PA for existing prescriptions for a 180-day transition period; this grandfathering and 180-day PA-free period do not apply to new prescriptions.
- For new prescriptions that require PA under Medi-Cal Rx (i.e., drugs/therapies not previously prescribed to the beneficiary), prescribers or pharmacists must submit a PA to Magellan consistent with Medi-Cal Rx policy and medical necessity review processes.
Claims and administrative services move to Magellan (MMA) on the effective date.
Medi-Cal Rx operational coverage and provider requirements
Operational requirements and provider actions for Medi-Cal Rx:
Includes claims processing and related tools administered by Magellan.
ALL of the following
- Providers (including pharmacies and prescribing physicians) must register for secure access to the Medi-Cal Rx Provider Portal to access beneficiary eligibility, web claims submission, prior authorization submission and inquiry, the Learning Management System (Saba), secure messaging, and secure chat.
- To register, use the 'Secured portal access' -> 'Provider Portal' -> 'Register' workflow on the Medi-Cal Rx website; complete required steps (UAC/PIN and Delegated Administrator setup) to obtain portal functionality.
Registration required to submit and manage PAs and claims via the portal.
ALL of the following
- While most pharmacies are enrolled as Medi-Cal FFS providers, some pharmacies used by managed care beneficiaries may not be enrolled; pharmacies that are not enrolled as FFS providers must enroll to submit claims and be paid under Medi-Cal Rx.
- Use the pharmacy locator (available December 2020) or Customer Service (1-800-977-2273 beginning January 1, 2021) to identify FFS-enrolled pharmacies.
ALL of the following
- Review the Medi-Cal Contract Drugs List (CDL) to determine which drugs are subject to prior authorization; the CDL will be available on the Medi-Cal Rx website starting January 1, 2021 and is updated monthly.
- Prescribers and pharmacists should verify current CDL status for medications when determining PA requirements under Medi-Cal Rx.
ALL of the following
- After completing UAC registration and Delegated Administrator setup, providers should enroll in Saba training (CBTs, job aids, webinars) and may request sessions via MediCalRxEducationOutreach@MagellanHealth.com.
- Subscribe to the Medi-Cal Rx Subscription Service (MCRxSS) and monitor the Medi-Cal Rx website for updates, FAQs, and policy information.
Contract Drug Lists and Codes
| Contract Drugs List (CDL) | List used to determine drugs subject to prior authorization under Medi-Cal FFS/Rx; updated monthly. |
Provider Requirements and Prior Authorization
Prior Authorization transition and requirements
DHCS established a transition policy that grandfathers previously approved prior authorizations from managed care and FFS through their stated duration and provides a 180-day period during which DHCS will not require PA for existing prescriptions. The grandfathering and 180-day PA-free period do not apply to new prescriptions; prescribers or pharmacists must submit PAs for new items requiring authorization under Medi-Cal Rx.
Provider portal registration and FFS enrollment
FFS-enrolled pharmacies do not need to cease services but must register for secure portal credentials to look up claims and submit claims and prior authorizations in Medi-Cal Rx. Pharmacies that are not enrolled as Medi‑Cal providers must enroll as FFS Medi‑Cal pharmacy providers to submit claims and be paid.
- Register for secure portal credentials via the Medi‑Cal Rx website to access claims and PA features.
- Non-enrolled pharmacies must enroll at https://pave.dhcs.ca.gov/sso/login.do to bill Medi‑Cal Rx.
Prior Authorization via Medi‑Cal Rx Provider Portal
Providers must register for and use the secure Medi‑Cal Rx Provider Portal beginning January 1, 2021 to submit and manage Prior Authorization requests (including submission, status inquiry, cancellation, and adding information to in‑progress requests).
- Use the Provider Portal for PA submission, status inquiries, cancellations, and attaching additional information or documents to in‑progress requests.
- Familiarize with the updated Contract Drug List (CDL) available on the Medi‑Cal Rx website.
Key Terms and Scope Definitions
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