The transition date of Medi-Cal managed care claims to fee-for-service is still set for April 1, 2021.
Medi-Cal Rx – the name of the new program – will apply to all pharmacy services billed on pharmacy claims. However, most DME claims are exempt. For a complete list of exempt products, visit Medi-Cal Rx website.
The existing Medi-Cal managed care pharmacy carve-outs will continue to be reimbursed in the same manner (e.g., blood factor, HIV/AIDS drugs, antipsychotics, or drugs used to treat substance use disorder).
The Department of Health Care Services (DHCS) promises that the entire dedicated Medi-Cal Rx website will be fully operational by April 1, 2021. In the meantime, DHCS encourages Medi-Cal providers, health plans, beneficiaries, and other interested parties to sign up for the Medi-Cal Rx Subscription Service, which sends Medi-Cal Rx updates by email.
DHCS will allow beneficiaries to have enough time during the transition period to work with their prescribers to either submit prior authorizations (TARs) based on medical necessity, or switch to a preferred Medi-Cal Rx covered drug. If a drug is not listed on the Medi-Cal Contract Drug List, a TAR will be required.
For all Medi-Cal beneficiaries with an existing prescription that did not require a TAR but will otherwise require it after the implementation, DHCS will use paid claims data received from Managed Care Plans to “look back” and validate that a prior prescription existed for the applicable medication.
For existing prescriptions with previously approved TARs, DHCS will use TAR history data to “grandfather” those prescriptions to allow continuation of the TAR through its stated duration, e.g., three months, six months, etc., but not to exceed one (1) full year from the original TAR start date.
Some additional changes:
- The DHCS will not enforce “6 prescriptions per month” requirement.
- The DHCS will not require pharmacy lock-ins as some managed care plans do.
- The DHCS plans to eliminate some co-pays and to have long-running TARs for certain conditions and classes of drugs. For example, TARs lasting up to 5 years, for such conditions as ADHD, Alzheimer and drugs as Antidepressants, hormone replacement and many others.
- The DHCS also plans to expand auto-adjudication functionalities to reduce the number of drugs with TAR requirements with manual review.
Prior to the implementation date, the DHCS encourages pharmacies to submit test transactions to ensure connectivity and uncover any software issues. If you would like to submit test claims, please email MRxPharmacyTesting@magellanhealth.com with your Contact Name, Phone Number, Pharmacy National Provider Identifier (NPI), and Switch information
DHCS will also be transferring previously established Electronic Fund Transfer (EFT) account information from the existing Medi-Cal fee-for-service (FFS) Fiscal Intermediary to Medi-Cal Rx. However, for those pharmacy providers that do not wish to have their EFT account information transferred over to Medi-Cal Rx for use after the April 1, 2021, assumption of operations, an option to “opt out” is available. Opt-out instructions.
Registered users who wish to provide new or modified EFT account information to Medi-Cal Rx for use after the Medi-Cal Rx assumption of operations may do so at this link.