On July 26, the California Department of Health Care Services (DHCS) and its Medi-Cal Rx contractor Magellan announced a delay in the first wave of reinstatement of prior authorizations for new start medications in 11 therapeutic drug classes from late August to Sept. 16.
In early June, DHCS and Magellan released their plan to reinstate pharmacy claim edits and prior authorization requirements for Medi-Cal outpatient pharmacy benefits through a phased approach. These edits and prior authorizations had been suspended since February as a result of Medi-Cal Rx implementation challenges.
Furthermore, this first wave of reinstatement of prior authorizations will only apply to new start prescriptions for adults ages 22 and older. The prior authorizations that have been suspended will not be reinstated for prescriptions for beneficiaries 21 and under.
As a reminder, CHA hosts calls with DHCS and Magellan every other Friday, which provide a forum for hospital pharmacy teams to get the latest information on Medi-Cal Rx and raise issues directly with the state and their contractor. As DHCS and Magellan continue to rollout their reinstatement of claim denial codes and prior authorization requirements, this forum will be an opportunity to provide direct feedback on the impact of these reinstated policies, which will be valuable in informing the planning and timing of subsequent phases of reinstatements. If you are not on this meeting series and would like to participate, please contact Barbara Roth to be added.