As of November 10, 2023, the Medi-Cal Rx Transition Policy has been retired for all pharmacy benefits for members 22 years of age and older. Note that members 21 years of age and younger will not be impacted at this time.
Prior authorization (PA) requirements have been reinstated for all therapies for standard therapeutic classes, including enteral nutrition products. Brand Medically Necessary (BMN) PA requirements are reinstated for all claims.
As part of this phase of the transition policy, the drug classes below now require a PA.
| Phase IV, Lift 4 Drug Classes | ||
| Protein Lysates | Infant Formulas | Electrolytes and Miscellaneous Nutrients |
What pharmacy providers and prescribers need to do
- Assess business processes and workflows to account for reinstatement of PA requirements.
- Consider alternate therapies that may not require a PA, if clinically appropriate. Review the Contract Drugs & Covered Products Lists page on the Medi-Cal Rx Web Portal.
- For more information on submitting a PA, refer to the Prior Authorization Submission Reminders alert and the Medi-Cal Rx Provider Manual.
For more details and resources, see the Oct. 10 DHCS announcement.
Questions?
You can call the Medi-Cal Rx Customer Service Center at 800-977-2273, which is available 24 hours a day, 7 days a week. You can also email Medi-Cal Rx Education & Outreach at [email protected].
