Introducing Medi-Cal Rx
On January 1, 2022, the Department of Health Care Services (DHCS) will change the pharmacy benefit for Medi-Cal members. Their prescription medications will be covered by a new program called Medi-Cal Rx. This does not change their Medi-Cal eligibility or benefits.
If the member is eligible for both Medicare and Medi-Cal, Medicare will continue to be the primary insurance coverage.
Prescription Billing for Medi-Cal Members After Medi-Cal Rx Transition (1/1/22 and after): Members need to bring their Benefits Identification Card (BIC) from Medi-Cal to the pharmacy with their prescriptions. Alliance identification cards cannot be used for Medi-Cal Rx billing.
|Medi-Cal Rx Customer Service Center 1-800-977-2273|
Please note: This does not affect IHSS members. IHSS members can continue using their Alliance ID card.
Understanding Changes in Pharmacy Benefits under Medi-Cal Rx.
Starting January 1, 2022, prescriptions that are filled at a pharmacy will be covered by Medi-Cal Rx instead of the Alliance. Medi-Cal Rx is a new program provided by the DHCS to provide pharmacy benefits for Medi-Cal members. DHCS is working with a new contractor called Magellan to provide Medi-Cal Rx services.
There is no change to physician-administered drug benefit and will continue to be covered by Alliance when billed as a medical claim with HCPCS code.
For Alliance Care IHSS members, there is no change to the pharmacy benefit.
Pursuant to Governor Newsom’s January 7, 2019 Executive Order N-01-2019, Medi-Cal pharmacy benefits will be transitioned to and thereafter administered through the fee-for-service delivery system for all Medi-Cal beneficiaries (generally referred to as “Medi-Cal Rx”). Medi-Cal Rx transitioning pharmacy services from Medi-Cal managed care to fee-for-service will, among other things:
- Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system.
- Improve access to pharmacy services with a pharmacy network that includes the vast majority of the state’s pharmacies and is generally more expansive than individual Medi-Cal managed care plan pharmacy networks.
- Apply statewide utilization management protocols to all outpatient drugs, as appropriate.
- Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers as the largest Medicaid program in the country with over 13 million beneficiaries.
Most Alliance members will be able to use the same pharmacy they do now on January 1, 2022. If their pharmacy is not contracted with Medi-Cal Rx, the member may need to choose another pharmacy. The pharmacy locator will be available in December 2020 on https://www.Medi-CalRx.dhcs.ca.gov.
Medi-Cal Rx does not have a preferred specialty pharmacy. Our current specialty pharmacy US Bioservices is contracted with Medi-Cal Rx.
Medi-Cal Rx secure Provider Web Portal https://www.Medi-CalRx.dhcs.ca.gov has key functions for provider and prescribers such as:
- Prior Authorization Information and Submittal Instructions
- Beneficiary Eligibility Look Up
- Web Claims Submission, Activities, and Inquiries.
For detailed registration and training instructions, access the Medi-Cal Rx Web Portal and Training Registration article located on the Pharmacy News Page or visit https://medi-calrx.dhcs.ca.gov/provider/ and click Register in the upper right hand corner.
It is important that registration be completed early so the users training and functionality are complete and active for use on January 1, 2022.
Yes, Medi-Cal Rx has their own formulary called Contract Drug List (CDL). It will be available on Medi-Cal Rx portal for providers starting November 2021: https://www.Medi-CalRx.dhcs.ca.gov.
- If the member was on a medication prior to 1/1/22 through Alliance, the same medication will be “grandfathered” for 180-day transition period. This means the members can continue to receive the same medications without prior authorization through June 2022. During 180-day period, the provider needs to submit a prior authorization for members to continue on the medication or switch to an alternative that is on CDL.
- If the member has never received the medication prior to 1/1/22, the provider will need to obtain a prior authorization from Medi-Cal Rx.
For drugs billed as pharmacy claims (prescriptions that members pick up from pharmacy), providers can submit prior authorization requests through Medi-Cal Rx Provider Portal, fax, or mail. Providers can check on the status of requests on Medi-Cal Rx Provider Portal or by phone to Medi-Cal Rx Call Center Line 1-800-977-2273. Please refer to https://www.Medi-CalRx.dhcs.ca.gov.
For physician-administered drugs billed as medical claims (drugs billed to Alliance as HCPCS code), providers can continue to submit requests through Alliance Provider Portal or by fax at (831)430-5851. There is no change to physician-administered drug benefit and will continue to be reviewed and covered by Alliance.
Authorizations will be carried over or “grandfathered” for their originally approved dates of services up to 1 year, unless the drug is included in the list of exceptions allowing for extended/multi-year PAs up to 5 years for certain drug classes/categories (liste below). New prior authorizations will be required from Magellan after the original prior authorization expires.
Drug classes/classifications include:
Diabetes (insulin and anti-diabetic drugs), Asthma/COPD (long and short acting bronchodilators, inhaled corticosteroids and combination products, antihistamines, epinephrine), Antidepressants, Anticonvulsants, Anti-Parkinson’s, Immunosuppressants (for prevention of transplant rejection and treatment of autoimmune disorders), Cardiovascular drugs (including antihypertensives, antiarrhythmics, alpha and beta blockers, inotropics, diuretics), Agents for chronic treatment of Rheumatoid Arthritis, Pulmonary Hypertension, Multiple Sclerosis, Attention Deficit Hyperactivity Disorder (ADHD), Alzheimer’s Disease, Gout, Antihyperlipidemics, Contraceptives, Glaucoma Agents, Hormone replacement, Thyroid disorders, drugs for overactive bladder, nasal steroids, treatment for allergies and cough.
Starting on January 1, 2022, providers can call the Medi-Cal Rx Call Center Line at 800-977-2273 (TTY: Dial 7-1-1) and a representative from the Medi-Cal Rx team at Magellan will be able to assist 7 days a week, 24 hours a day.
If providers have questions before January 1, 2022, please call the Alliance Provider Services Department.
Prior to 1/1/22, providers can contact Alliance Pharmacy Department at (831) 430-5507.
1/1/22 and after, please contact Medi-Cal Rx Call Center Line at 800-977-2273.
Contact Pharmacy Department
Monday-Friday, 8 a.m. to 5 p.m.