Medi-Cal managed care plans inappropriately denying claims for physician administered drugs

January 20, 2022

The California Department of Health Care Services (DHCS) has received concerning reports of denials or impeded access to physician administered or infused drugs–such as chemotherapeutic agents, anti-rejection medications for organ transplants, and long-acting contraceptives–since the transition to the Medi-Cal Rx program on January 1.

Although DHCS has been clear that physician administered or infused drugs billed on a CMS 1500 form are not part of the Medi-Cal Rx transition, there has been confusion where some Medi-Cal managed care plans or their delegated groups are inappropriately telling physicians to bill the Medi-Cal Rx program.

Late last week, DHCS sent a notice to the Medi-Cal managed care plans to them of their obligations to continue to provide access to prescription drugs administered by a health care professional in a clinic, physician’s office or outpatient setting.

Medi-Cal managed care plans who have excluded prescription drugs that were formerly available through the medical benefit or have directed their subcontractors or network providers to no longer bill for prescription drugs through their medical claims have been directed to take immediate action to reinstate coverage for these drugs.

Medi-Cal managed care plans are required to retain physician administered drugs as a medical benefit, even though some may also be available as a pharmacy benefit when it is medically appropriate. These prescription drugs should always remain a medical benefit even when they are also available as a pharmacy benefit.

If your practice is experiencing problems billing for physician administered drugs under the Medi-Cal managed care program, please contact the California Medical Association at (800) 786-4262 or economicservices@cmadocs.org.


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