Medi‑Cal pharmacy benefit carve‑out to Medi‑Cal Rx
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Announces transition of Medi‑Cal pharmacy benefits from Health Net managed care to the State's Medi‑Cal Rx program effective January 1, 2021; affects Physicians, Participating Physician Groups, Hospitals, Ancillary providers and Medi‑Cal members in specified counties.
Medi‑Cal pharmacy benefits and services will transition from managed care to the State's Medi‑Cal Rx effective January 1, 2021 and Magellan will administer Medi‑Cal Rx.
Providers must engage Magellan directly for pharmacy benefit issues and provider training starting January 1, 2021.
Health Net will retain responsibility for care coordination and certain clinical oversight functions, and will continue to process medical/institutional claims when applicable.
Which Services Transition to Medi‑Cal Rx
Coverage transfer criteria
Which services move to Medi‑Cal Rx and which remain with Health Net/managed care:
ALL of the following
Services that move to Medi-Cal Rx
- Covered outpatient drugs, including physician-administered drugs dispensed by a pharmacy, when a patient normally receives them from a pharmacy
- Medical supplies dispensed by a pharmacy, when a patient normally receives them from a pharmacy
- Enteral nutritional products dispensed by a pharmacy, when a patient normally receives them from a pharmacy
Services that remain with Health Net / are excluded from the fee-for-service transition
- Pharmacy services provided in inpatient or long-term care settings (including skilled nursing facilities and intermediate care facilities) are excluded from the transition to fee-for-service Medi-Cal Rx
- Health Net retains oversight and care coordination responsibilities, oversight of certain clinical pharmacy adherence activities (pending DHCS guidance), and processing/payment of services billed on medical and institutional claims when approved through Health Net prior authorization; claims processed by a pharmacy should be billed directly to Magellan.
Coding & Operational SLAs for Carved-Out Pharmacy Services
| No codes listed |
What Providers Must Do
Engage Magellan for prior authorization, claims, and training starting 1/1/2021
Effective January 1, 2021, providers must engage Magellan directly for prior authorizations, claims adjudication, and to establish any required Medi‑Cal Rx provider training for pharmacy services provided on and after that date.
- Contact Magellan for resolution of member pharmacy prescription benefit issues for services on/after 1/1/2021.
- Contact Magellan to establish and set up any required Medi‑Cal Rx provider training.
Definitions and Scope of Carved‑Out / Excluded Services
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