Medi-Cal Rx implements utilization management criteria for Code 1 diagnosis restricted drugs

April 30, 2024

Effective April 30, 2024, the California Department of Health Care Services (DHCS) has turned on claim utilization management edits for Reject Code 80 – Diagnosis Code Does Not Meet Drug Coverage Criteria for beneficiaries 22 years of age and older.

When submitting a prescription for a drug on the Code 1 diagnosis restricted list, prescribers must now demonstrate that the diagnosis restriction is met by completing one of the following actions:

  • Submitting a qualifying diagnosis from the Code 1 diagnosis restricted list with the electronic prescription;
  • Submitting a prior authorization request through an approved Medi-Cal Rx submission method establishing the Code 1 diagnosis restriction is met or establishing medical necessity for an alternative diagnosis; or
  • Providing a qualifying diagnosis verbally to the pharmacy provider.

DHCS also advised that Medi-Cal Rx will utilize diagnosis codes from the patient’s medical record, if available, to meet the requirement. However, absent a clear way to identify whether a qualifying diagnosis is on file, this method could result in duplicative work and delays patient access to medications.

Code 1 restricted drugs that do not meet one of the above requirements will be denied coverage with Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.

Although California has several laws that protect patient privacy related to disclosure of reproductive health, gender-affirming care and mental health services, DHCS has elected to keep some medications associated with these services on the Code 1 restricted drug list. Practices concerned about privacy issues associated with submitting a diagnosis to a pharmacy may wish to seek a prior authorization from Medi-Cal Rx rather than submitting a diagnosis code to the pharmacy.

Physicians can review the Code 1 restricted drug list to identify the drugs and qualifying diagnosis codes subject to the requirement.

Prescriptions for pediatric patients (21 years of age and under) are excluded from the requirement at this time.

For more information on implementation of Reject Code 80 or how to submit a prior authorization request, click here.

For questions, please contact the Medi-Cal Rx Customer Service Center at (800) 977-2273 or MediCalRxEducationOutreach@primetherapeutics.com.


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