April 08, 2025
What You Need to Know: On April 25, Medi-Cal Rx will reinstate prior authorization requirements for all continuation of therapy claims for members 21 years of age and younger.
In March 2022, the California Department of Health Care Services (DHCS) suspended Medi-Cal Rx prior auth requirements to ensure patients maintained timely access to pharmacy benefits. While previous phases of the Medi-Cal Rx transition plan restored prior auth requirements for patients 22 and older, claim edits and prior auth requirements remained suspended for Medi-Cal Rx covered pharmacy claims for members 21 years of age and younger until this year.
In January 2025, Medi-Cal Rx reinstated claim edits and prior authorization requirements on new start prescriptions for patients 21 years of age and younger, as part of the planned "pediatric integration." Effective April 25, 2025, Medi-Cal Rx will complete the Pediatric Integration by reinstating prior authorization requirements for all continuation of therapy claims for members 21 years of age and younger.
Additional details can be found on the “Pediatric Integration” tab in the Medi-Cal Rx Web Portal.
More information can also be found in the 30-day notice, “30-Day Countdown: Completion of Pediatric Integration of Members 21 Years of Age and Younger.”
This will mark the end of the Medi-Cal Rx transition.