Prescription Drug Program
- Participating Physician Groups (PPG)
The following medications are covered under Health Net's Medi-Cal plan:
- Medications administered while the member is hospitalized or in an emergency room
- Medications administered in a provider’s office or infusion center billed through the medical benefit
- Home infusion or other medication-related services billed through the medical benefit
The following medications are covered by the Medi-Cal Rx program
- Self-administered and provider-administered medications listed on the Medi-Cal Rx Contract Drug List (CDL) and billed through a pharmacy
- Self-administered and provider-administered medications not listed on the Medi-Cal Rx CDL billed through a pharmacy (prior authorization may be required)
- Medications prescribed by a psychiatrist that are on the Medi-Cal Rx CDL and filled at a participating Medi-Cal Rx pharmacy
- A 72-hour supply of a covered medication in a medical emergency.
- Medical supplies, including personal home-use blood pressure monitors and blood pressure cuffs for use with personal, home blood pressure monitoring devices, and therapeutic continuous blood glucose monitors are a covered benefit under Medi-Cal Rx.
Medications for the treatment of AIDS and HIV are excluded from Health Net's coverage responsibilities and are covered under the DHCS Medi-Cal FFS program and Medi-Cal Rx. Refer to the discussion of carve-out medications in this section for more information.
Health Net Medi-Cal does not cover health care services for California Children's Services (CCS)-eligible conditions, but they are covered under the CCS program. Prescriptions written for children with CCS active conditions need to be written by a CCS-paneled provider and billed directly to CCS.
Due to the passage of federal legislation (HR 3971), where federal financial contribution has been discontinued for all medications used to treat sexual or erectile dysfunction, the state of California has decided to discontinue coverage of such medications under the Medi-Cal program, unless used to treat a condition other than sexual or erectile dysfunction.
The Department of Health Care Services (DHCS) has carved out selected psychotherapeutic, coagulation factors, HIV-related medications and medications to treat alcohol or drug dependence from Health Net's coverage responsibilities. These medications are covered by the Medi-Cal Rx program. Pharmacies bill Medi-Cal Rx directly for these medications.
For a list of carved-out AIDS and HIV treatment medications, refer to the Excluded Medications for HIV and AIDS discussion in the AIDS Waiver Program section of the Public Health topic.
For a list of carved-out psychotherapeutic medications, refer to the Excluded Psychotherapeutic Medications discussion in the Mental Health section of the Public Health topic.
Health Net Medi-Cal does not cover health care services, including prescription medications, for California Children's Services (CCS)-eligible conditions, but they are covered under the CCS program. Prescriptions written for children with CCS-active conditions must be written by a CCS-paneled provider and billed directly to CCS.
The Medi-Cal Rx Contract Drug List (CDL) is available on Health Net's provider portal, located under Pharmacy Information > Drug Information for California State Health Programs. The Medi-Cal Rx CDL is found on the Medi-Cal Rx website.
Certain medications on the Medi-Cal Rx CDL require prior authorization for coverage. Medications not found on the Medi-Cal Rx CDL may require prior authorization.
Prior Authorization can be requested in the following ways:
- By going to cover my meds.
- By logging into the portal and submitting the PA through our Prior Authorization tool. Login from the provider portal and access the secured Prior Authorization tool.
- By sending a completed PA form through fax to Medi-Cal Rx fax number.
- By submitting a NCPDP P4 Transaction through Pharmacy POS system.
- By sending a completed PA form through mail to Medi-Cal Rx Customer Service Center
For additional information, refer to the Medi-Cal Rx Options for PA Submission Guide.
Medi-Cal Rx will notify providers of the status of prior authorization requests.
Nutritional supplements and replacements are a conditional benefit for Health Net's Medi-Cal members and may be covered subject to prior authorization. Requests for oral formula that are obtained under the pharmacy benefit should be submitted to Medi-Cal Rx. Requests requiring a pump, supplies needed to administer the formula, or formula that cannot be billed through the pharmacy should be submitted to Health Net Medi-Cal Health Services Department.
Depending on capitation status, the request is then forwarded to the Health Net Medi-Cal Health Services Department or to the appropriate participating physician group (PPG) to facilitate further prior authorization.
Special infant formula requests for members with conditions that make them eligible for services through public health carve-out programs must be referred to the public health program agencies. Such carve-out programs include California Children's Services (CCS) and Genetically-Handicapped Persons Program (GHPP).
In Los Angeles County, practitioners affiliated with Molina Healthcare, a subcontracting health plan, must follow Molina's prior authorization requirements when requesting special infant formulas for Health Net members assigned to Molina Healthcare. Contact the Molina Pharmacy Department for more information.