July 21, 2022
Area(s) of Interest: Payor Issues and Reimbursement Public Payors
The California Department of Health Care Services (DHCS) has elected to postpone implementation of Medi-Cal Rx Reject Code 80, despite recently announcing it would be included in the first of three phases to reinstate pharmacy claim edits and prior authorization requirements for prescription drugs. Drug Utilization Review edits (DUR 88) will take effect July 22, 2022, as previously announced.
Earlier this year the DHCS began waiving prior authorizations from 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.
In the first of the three phases, claim edits for Drug Utilization Review edits will be turned on effective July 22, 2022. DUR Reject Code 88 alerts are triggered by instances such as drug-drug interactions, high dose, early refills, etc.
DHCS has decide to further delay implementation of Reject Code 80 (Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria) due to stakeholder feedback that implementation of Reject Code 80 could necessitate submission of prior authorizations prior to the timeframe targeted for prior authorization reinstatement, which could interfere with the delivery of timely and safe pharmacy services to Medi-Cal beneficiaries.
Although claims submitted to Medi-Cal Rx will not be edited for a diagnosis code, DHCS is reminding providers of their obligation to meet and document Code 1 restrictions and to keep that information readily available.
It is unclear when Reject Code 80 will be turned back on. However, DHCS has previously indicated that sometime in August, the following drug classes will again require prior authorization:
- 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
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.