Reducing unnecessary visits to the emergency department
Our data shows that members may frequently visit the emergency department for preventable conditions. The Alliance is working to educate members about when and where to seek care.
Our key messages to members include:
- Visits to the emergency room are mainly for life-threatening conditions.
- For routine care, members should visit their primary doctor.
- If a member cannot see their doctor, they can call the Nurse Advice Line or go to urgent care.
We will be distributing this information to members via our website and the December edition of our member newsletter. We want to help members understand the best way to get care and consider available options to address preventable conditions.
To help encourage members to use the Nurse Advice Line, we have flyers available to print and download in English, Spanish and Hmong. We also have Nurse Advice Line magnets available. If you would like some to distribute to members, please contact your Provider Services Representative.
Thank you for partnering with us and for providing accessible, quality health care to our communities!
Medi-Cal Rx Phase I, Wave III: Prior authorization reinstatement for 11 drug classes
On September 16, 2022, prior authorization (PA) requirements will be reinstated for 11 drug classes for new start medications for patients who are 22 years of age and older.
“New starts” are new therapies or medications not previously prescribed to a patient during the 15-month lookback period. Claims data and PAs will be used to review for grandfathering.
Drug classes
The drug classes include:
- Diuretics.
- Antilipemic agents (including statins and omega-3 fatty acids).
- Hypoglycemics and glucagon.
- Antihyperintensives.
- Coronary vasodilators (nitrates and pulmonary arterial hypertension agents).
- Cardiovascular agents (including antiarrhythmics and inotropes).
- Anticoagulants and antiplatelets.
- Niacin, Vitamin B and Vitamin C products.
Important notes
- New start prescriptions for children and youth 21 years old and under within these 11 drug classes will not be subject to PA reinstatement.
- Medi-Cal Rx product-specific coverage criteria for enteral nutrition products and medical supply products have not been changed or waived.
- For prescriptions requiring a PA that do not have an approved PA (or a historical claim) on file, PA requirements will remain in place.
Webinars
Magellan is hosting live reinstatement webinars on Sept. 16 and Sept. 23 from noon-1 p.m. Webinars include a 30-minute presentation about reinstatement followed by a Q&A. The Zoom link is the same for all sessions. No registration is required.
A pre-recorded version is also available: Medi-Cal Rx Pre-recorded Reinstatement Webinar.
Resources
- Medi-Cal Rx Phase I, Wave III – Frequently Asked Questions.
- Prior Authorization Reinstatement Reference Guide: includes information on the five ways to submit a PA, helpful reminders for completing PAs and a list of resources available on the Medi-Cal Rx Web Portal.
- Phase I, Wave III List of Drugs Impacted by Prior Authorization Reinstatement: the Medi-Cal Rx Approved National Drug Code (NDC) List identifies each drug that has a PA requirement. This list will be updated monthly until reinstatement is completed.
Drug regimen safety: concurrent use of opioids and benzodiazepines
Tapering benzodiazepine dosages
If benzodiazepines are overprescribed or co-prescribed with opioids, patients may experience serious side effects, including death. It is important to limit benzodiazepine dosage and duration to the minimum needed to achieve the necessary clinical effect.
Providers should regularly reassess the need for benzodiazepines for patients and discuss strategies for discontinuation. Please review your patients’ medical profiles and if appropriate, consider tapering/discontinuing benzodiazepines to improve the safety of their drug regimen.
Please note:
- Tapering schedules should be individualized for each patient.
- Dosage should be adjusted based on the patient’s response.
Based on the patient, a rapid or slow taper may be appropriate.
- Rapid taper may be considered for patients who have taken benzodiazepines for less than four weeks. In this method, benzodiazepine discontinuation takes place by a relatively larger drop in dose and more frequent dose reduction than in a slow taper. A rapid taper might involve an initial 25-30% dose reduction weekly until 50% of the dose is reached, followed by 5-10% dose reductions weekly.
- Slow taper should be considered for patients who have been on benzodiazepines for longer than 4 weeks. A common approach is an initial dose reduction of 5-25%, followed by further reductions of 10-25% every two weeks.
If withdrawal symptoms occur during a taper, return to the dose prior to the most recent reduction and slow the rate of the taper.
For more information, including examples of benzodiazepine tapers, refer to the DHCS Clinical Review: Recommendations for the Tapering of Benzodiazepines.
Naloxone for patients
California prescribers are required to offer naloxone or another drug approved by the FDA for the complete or partial reversal of opioid-induced respiratory depression as a rescue medication when one or more of the following conditions are present:
- The prescription dosage for the patient is ≥ 90 mg morphine equivalent daily dose (MEDD).
- An opioid medication is prescribed concurrently with benzodiazepine or other CNS (central nervous system) depressants.
- The patient presents with an increased risk for overdose, including a history of overdose, a history of substance use disorder or a risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.
Please review your patients’ medical profiles and if appropriate, consider prescribing/furnishing naloxone to improve the safety of your patients’ drug regimens.
Note: These naloxone prescription requirements became effective per AB 2760 on January 1, 2019.
For additional information, you can review the Medical Board of California’s AB 2760 FAQs.
Updates to the Data Submission Tool Guide
To help providers get the most out of our Data Submission Tool in the Provider Portal, the Alliance has recently added the following items to the Data Submission Tool Guide.
- Depression screening and follow-up plan data type.
- Immunization codes.
- Immunizations: Children – 90697.
- Immunizations: Adolescents – 90733.
- Immunizations: COVID-19 – 91308, 91309, 91311.
- Added clarification that BMI percentile must be noted and calculated in the medical record and that BMI values cannot be submitted via the DST.
- Added HCPCS codes for Unhealthy Alcohol Use in Adolescents and Adults.
Please make sure to download the most recent Data Submission Tool Guide when you log in to the Provider Portal.
We hope you find these additions to be helpful. If you have any questions, you can reach out to your Provider Relations Representative.
