Medi-Cal Rx reinstates prior auth requirements for more pharmacy benefits

November 14, 2023

On November 10, 2023, the California Department of Health Care Services (DHCS) implemented Phase IV, Lift 4 of the Medi-Cal Rx transition plan. Under Phase IV, Lift 4, prior authorization requirements have been reinstated for all therapies for standard therapeutic classes 68, 86 and 87, which includes enteral nutrition products, and Brand Medically Necessary prescriptions for members 22 years of age and older.

DHCS also recently announced that based on stakeholder feedback it would not reinstate Reject Code 80 (Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria) for Code 1 drugs on November 10, 2023, as previously announced. Medi-Cal Rx will continue to engage with stakeholders on the reinstatement of Reject Code 80 and will provide notice at least 30 days in advance of an implementation date.

Last month, DHCS reinstated Reject Code 76 (Plan Limitations Exceeded), under Phase IV, Lift 3.

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