Medi-Cal Rx: Understanding the Upcoming Changes

Brooke Phillips, CWCMS
Editor | Shield HealthCare
10/26/20  2:03 PM PST

Watch our video above, and read on for more information.

What is Medi-Cal RX?

In January of 2019, California Governor Gavin Newsom signed an executive order which requires the state to move pharmacy benefits out of Medi-Cal Managed Care and back into Medi-Cal Fee-for-Service by January 1,2021. “Medi-Cal Rx” is the name of this program.

The California Department of Health Care Services will be implementing the Medi-Cal Rx program beginning January 1, 2020. A large Pharmacy Benefits Administrator (PBA) called Magellan has been hired by the State of California to manage this program.

Why is Medi-Cal RX Happening?

The state believes that this program will help California to standardize the pharmacy benefit. The state can apply uniform standards, and it can provide better access to drugs for pharmacy patients.

The state will also have more control over their supplemental drug rebates. The Medi-Cal Rx program is anticipated to save significant money for California taxpayers.

What Supplies Does Medi-Cal RX Cover?

The Medi-Cal Rx program covers pharmacy products that are billed on pharmacy claim forms. This includes items such as outpatient drugs, physician-administered drugs, enteral formula, and certain medical supplies that are billed on pharmacy claim forms.

The Medi-Cal Rx program DOES NOT include Durable Medical Equipment (DME), or supplies billed on non-pharmacy claim forms.

Who is Impacted?

The state estimates that over 13 million people will be in the Medi-Cal Rx program. This includes everyone in California Children’s Services (CCS) and Medi-Cal (both Fee-for-Service and Managed Care) – including SCAN and the AIDS Healthcare Foundation.

However, Californians that are enrolled in PACE or Cal MediConnect will not be impacted at all.

How Does This Affect HealthCare Professionals?

Future referrals for enteral formula may require prior authorization from Magellan Medicaid Administration. Please note, existing health plan authorizations may no longer be good soon after the transition, so new documents may be requested for your patients.

Shield HealthCare will continue coordinate each patient’s prior authorizations for both formula and supplies. If you currently refer patients to Shield, no action is needed – there will be no change. If you are referring your first patient to Shield, it’s easy! Just fax your patient’s information and supply orders to your local sales office. A representative will call you within 24 hours.

Shield HealthCare is working to make this transition as seamless as possible, and our Registered Dietitians and Customer Service Representatives are available to answer any questions regarding how you or your patients can obtain their supplies.

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