August 31, 2023
The California Department of Health Care Services (DHCS) recently initiated Phase IV, Lift 2 (P4/L2) of the Medi-Cal Rx transition, which will reinstate prior authorization requirements for new start therapies for standard therapeutic classes 68, 86, and 87, which includes enteral nutrition products, effective September 22, 2023.
P4/L2 will also reinstate utilization management claim edits for Reject Code 78 – Cost Exceeds Maximum. Beginning Sept. 22, prior authorization requests may be submitted in advance of the retirement of the transition policy for renewing/refilling prescriptions for products in classes 68, 86, and 87 (anticipated implementation in November 2023)
Claims for members 21 years of age and younger will not be impacted.
For more information: 30-Day Countdown: Reinstatement of Cost Ceiling and Prior Authorization for Enteral Nutrition and Specific Standard Therapeutic Classes.