DHCS to begin reinstating drug prior authorization and claim edits

June 28, 2022
Area(s) of Interest: Payor Issues and Reimbursement Public Payors 

The California Department of Health Care Services (DHCS) recently announced that it would soon begin reinstating pharmacy claim edits and prior authorization requirements for prescription drugs.

Earlier this year, DHCS began waiving prior authorizations under the Medi-Cal RX program retroactive to January 1, 2022, to minimize disruptions in patient access to prescription medications that occurred due to challenges with the Medi-Cal Rx transition.

Now that the Medi-Cal Rx call center and prior authorization operations have stabilized, DHCS will be implementing a three-phased approach to phase out the earlier mitigation actions and transition policy.

According to DHCS, the reinstatement approach is gradual and iterative with intense focus on stakeholder preparedness and performance monitoring. It will be refined as necessary over time based on data analytics, operational experience, and stakeholder feedback.

During the first of the three phases claim edits for diagnosis and Drug Utilization Review requirements, referred to as DUR 88 and Reject Code 80 edits, will be reinstated effective July 22, 2022. And in August, the following drug classes will again require prior authorization:

  • Diuretics
  • Lipotropics, including statins and omega‐3 fatty acids
  • Hypoglycemics, including glucagon
  • Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
  • Cardiovascular agents, including antiarrhythmics and inotropes
  • Anticoagulants and antiplatelets
  • Niacin, Vitamin B, and Vitamin C products

For more information, see DHCS’s “Medi-Cal Weekly Wrap-Up for June 17-June 23” and “Medi-Cal Rx Reinstatement Plan Phase I, Wave I: Frequently Asked Questions (FAQs).

Stay up to date with the latest Medi-Cal Rx news by signing up for the Medi-Cal Rx Subscription Service. For questions, please contact the Medi-Cal Rx Customer Service Center at (800) 977-2273, available 24 hours a day, 365 days a year, or email MediCalRxEducationOutreach@magellanhealth.com.


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