Medi-Cal to reinstate prior authorization for 11 drug classes on Sept. 16

July 28, 2022

The California Department of Health Care Services (DHCS) announced that Medi-Cal Rx prescribers will again be required to submit prior authorizations (PAs) for new start medications in 11 drug classes for patients 22 and older effective September 16, 2022.

The 11 drug classes include:

  • 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

According to DHCS, new start prescriptions for pediatric patients 21 years of age and under are excluded to prevent additional administrative obligations for providers of specialty pediatric services who have been significantly impacted by the transition to Medi-Cal Rx.

According to DHCS, these modifications were made based on stakeholder engagement and will enable the department to further assess impacts and identify opportunities to improve awareness about the Medi-Cal Rx prior authorization reinstatement plan.

Earlier this year the DHCS began waiving Medi-Cal Rx prior authorizations  to minimize disruptions in patient access to prescription medications due to challenges with the Medi-Cal Rx transition.

In the first of the three reinstatement phases, claim edits for Drug Utilization Review edits were 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.

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.

Practices can also contact the California Medical Association’s Center for Economic Services for assistance at economicservices@cmadocs.org or (888) 404-5911.


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