Provider Digest | Issue 5


COVID-19 preventive medication for immunocompromised members  

The Alliance is pleased to announce that Evusheld™ is available for Alliance members 12 years and older with moderate to severe immunocompromising conditions. Evusheld™ is given in two injections and is recommended every six months. It is available to members at no cost to members.  

¿Para quién es Evusheld™?  

Evusheldis for people who have a higher risk for severe COVID-19 disease and complications. Members can receive Evusheld medication if they have not been exposed to COVID-19 recently and they: 

  • Tiene un sistema inmunitario comprometido, de moderado a grave, debido a una condición médica. 
  • Cannot get a COVID-19 primary series or booster because they have a history of a severe reaction to COVID-19 vaccine(s) or COVID-19 vaccine ingredient(s). 
  • Tomó medicinas o recibió tratamientos que inhiben el sistema inmunitario.  

¿Quién no debe usar Evusheld™? 

Members may not be able to get the Evusheld treatment if they: 

  • Tiene alergias. 
  • Padece trastornos hemorrágicos. 
  • Tiene un conteo bajo de plaquetas. 
  • Tiene un historial o riesgo de ataque cardiaco o de accidente cerebrovascular. 
  • Está embarazada o planea embarazarse. 
  • Está en el periodo de lactancia materna. 

Alliance outreach to members 

At the direction of the California Department of Health Care Services (DHCS), the Alliance will be reaching out to members who may have conditions that would make them eligible for Evusheld™. We will contact these members by phone to inform them that they may be eligible and recommend that they reach out to their primary care team to discuss whether Evusheld™ is indicated. 

Primary care providers may locate pharmacies stocking Evusheld using the U.S. Department of Health & Human Services COVID-19 Therapeutics Locator. If you have any questions, please contact your Provider Relations Representative at 800-700-3874, ext. 5504.

Have you completed your ACEs training and attestation? 

The California Department of Health Care Services (DHCS) is monitoring all Medi-Cal health plans’ performance on adverse childhood experiences (ACEs) screenings. Primary care providers should complete these screenings. Before submitting a claim for the service, you must complete the required training and the self-attestation. Providers are eligible to receive CME credits upon completion.  

Complete the training 

Complete the required ACEs training. It is free and takes approximately two hours to complete. 

To start your training, you will need to visit the ACEs Aware course page. Log in or register, then navigate to My Courses to complete the training.  

Complete your attestation  

Once you have completed your training, complete the self-attestation so you can receive payment for subsequent ACE screenings you conduct. 

You will need your: 

  • National Provider Identifier (NPI). 
  • Clinic name and address. 

Please make sure your attestation information is complete and accurate.  

Billing and payment information 

Once you complete your training and attestation, the Alliance will receive notification of completion at the beginning of the following month. You can start billing the Alliance for these screenings after the first of the next month. For example, if you completed training and attestation on July 5, 2022, then the screenings you completed after July 5 can be submitted to the Alliance after August 1. Otherwise, the claims will be denied.  

Providers will receive payment of $29.00 for each screening through Prop 56 funding. Federally Qualified Health Centers (FQHCs) are eligible to receive the $29.00 payment for ACE screenings in addition to their existing Prospective Payment System payment. However, the patient’s visit must be billed on a separate claim to be qualified for the ACEs screening. 

 Care-Based Incentive (CBI) measure 

ACEs screenings are part of the 2022 CBI program as an Exploratory Measure. This measure is being considered as a paid measure for the 2023 program. For more information on billing, resources and measure information, please see the CBI ACEs Screening in Children and Adolescent tip sheet 

If you have any questions on ACEs training and screenings, please email the Alliance at [email protected] 

Medi-Cal Rx updates: Changes to phased reinstatement plan 

Reject Code 88 reinstated 

Effective July 22, 2022, DHCS began Phase I, Wave I of the Medi-Cal Rx Reinstatement Plan.  

Initially, Wave I was to reinstate two claim edits: DUR Reject Code 88: Drug Utilization Review Reject Error and Reject Code 80: Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria. However, based on analysis of stakeholder feedback and claims data, DHCS is postponing the reinstatement of Reject Code 80 because it could require submission of prior authorizations before the reinstatement date. Thus, in the current wave, Reject Code 88 has been reinstated, while Reject Code 80 has not. 

For more information, please refer to the July 22 Medi-Cal Rx bulletin (about Reject Code 88) y del July 12 Medi-Cal Rx bulletin (about Reject Code 80) 

Reinstatement of prior authorizations (PAs) for 11 drug classes starting Sept. 16 

Phase I, Wave III requires providers to submit PAs for new start medications in 11 identified drug classes, including: 

  • Diuretics. 
  • Lipotropics, including statins and omega-3 fatty acids. 
  • Hypoglycemics, including glucagon. 
  • Coronary vasodilators (nitrates and pulmonary arterial hypertension agents). 
  • Cardiovascular agents, including antiarrhythmics and inotropes. 
  • Anticoagulants and antiplatelets. 
  • Niacin, Vitamin B, and Vitamin C products.   

Note that this does not include new prescriptions for children and youth 21 years of age and under.  

For more details, review the July 26 Medi-Cal Rx bulletin 


For help with claims or PAs: 

  • Call the Medi-Cal Rx Customer Service Center (CSC) at 800-977-2273. You can also submit questions via email to Medi-Cal Rx Education & Outreach at [email protected].