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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsPHC California COVID Therapeutics Coverage | OpenP…
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    CurrentPHC CaliforniaPolicy UM 20.4

    PHC-CA COVID-19 Therapeutics

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    Governs access to COVID-19 vaccinations and medically necessary COVID-19 therapeutics for PHC California enrollees, including provider evaluation, prescribing, pharmacy access, prior authorization, and case management support.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA COVID-19 Therapeutics
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date07/21/2022
    Next Review DateAt least annually
    Key ActionObtain Utilization Management prior authorization for COVID-19 therapeutics administered by a healthcare professional.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    NoneVaccination prior authorization
    $0Oral therapeutic copayment
    10 daysExposure period
    AnnualReview frequency

    COVID-19 Vaccination and Therapeutic Coverage

    COVID-19 Vaccination and Therapeutic Access

    Covered when the applicable access requirements are met.

    COVID-19 vaccination: The enrollee accesses vaccination through the Medi-Cal Rx benefit.

    No prior authorization is required for COVID-19 vaccination.

    Medically necessary COVID-19 therapeutics: The enrollee has completed an evaluation by a provider and the provider has placed a prescription or order for the therapeutic.

    Prescribed oral therapeutics may be obtained from pharmacies with no copayment.

    Provider-administered therapeutics: The therapeutic requires administration by a healthcare professional and Utilization Management prior authorization is obtained.

    Timeliness and monitoring standards for Utilization Management decisions are addressed in Policy and Procedure UM 22 PHC-CA Authorization Referral Process.

    Policy Summary
    PayerPHC California
    PolicyPHC-CA COVID-19 Therapeutics
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective Date07/21/2022
    Next Review DateAt least annually
    Key ActionObtain Utilization Management prior authorization for COVID-19 therapeutics administered by a healthcare professional.
    SourceLink
    On This Page
    COVID-19 Vaccination and Therapeutic CoverageProvider Requirements and AuthorizationPolicy BackgroundMedical Necessity DefinitionInitial COVID-19 Therapeutic Access

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Services that are experimental, investigative, or research in nature are excluded from the definition of medically necessary services and are not covered under this policy.

    Provider Requirements and Authorization

    Prior Authorization

    Obtain prior authorization for provider-administered therapeutics

    COVID-19 therapeutics that require administration by a healthcare professional must be prior authorized by the Utilization Management department before the service is provided.

    • Authorization decision timeliness and monitoring standards are addressed in Policy and Procedure UM 22 PHC-CA Authorization Referral Process.
    Documentation Required

    Complete evaluation and prescribing or ordering

    A provider must evaluate the enrollee and place a prescription or order before medically necessary COVID-19 therapeutics can be accessed.

    Denial Risk

    Avoid experimental or investigational services

    Services that are experimental, investigative, or research in nature do not meet the policy’s definition of medically necessary services and may be denied on that basis.

    Policy Background

    PHC California provides access to COVID-19 vaccination through the Medi-Cal Rx benefit and supports access to medically necessary COVID-19 therapeutics following provider evaluation and prescribing or ordering. Network providers receive education regarding COVID-19 testing, outpatient pre-exposure prophylaxis, treatment, Test to Treat locations, infusion resources, and applicable NIH and public health guidance.

    Medical Necessity Definition

    Medically necessary or medical necessity
    Core definitionReasonable and necessary services to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury.
    Growth and developmentServices necessary to achieve age-appropriate growth and development are included.
    Functional capacityServices necessary to attain, maintain, or regain functional capacity are included.
    Acceptance and evidenceThe service should be widely accepted among practicing health care providers and based on evidence-based scientific criteria.
    Safety and exclusionsThe service must be reasonably safe and must not be experimental, investigative, or research in nature.

    Initial COVID-19 Therapeutic Access

    Initial COVID-19 Therapeutic Access

    Initial access requires provider evaluation and prescribing or ordering.

    Provider evaluation and prescription/order: A provider must evaluate the enrollee and place a prescription or order before medically necessary COVID-19 therapeutics are accessed.

    Provider-administered therapeutics additionally require prior authorization by the Utilization Management department.