22-708m Find Out What Changed: Reinstatement of Prior Authorizations for Several Drug Classes Under Medi-Cal Rx
Date: 08/31/22
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.
DHCS reviewed input from providers and beneficiaries as critical to the design of the reinstatement plan
The Department of Health Care Services (DHCS) has changed the Phase I, Wave III requirements that providers submit prior authorizations (PAs) for new start medications in several drug classes.1
PA requirements are being applied for the following therapeutic drug classes:1
- Anticoagulants and antiplatelets
- Cardiovascular agents, including antiarrhythmics and inotropes
- Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
- Diuretics
- Hypoglycemics, including glucagon
- Lipotropics, including statins and omega‐3 fatty acids
- Niacin, Vitamin B and Vitamin C products
Changes to the PA reinstatement plan include:
- Wave III, which was previously targeted for late August, will be implemented on September 16, 2022, to allow for the September updates to the Contract Drugs List to take effect, as well as more time for provider readiness and education, and analysis of the impact of Phase I, Wave I.1
- New prescriptions for beneficiaries ages 21 and under, for medications within the affected drug classes, are excluded. Specifically, new start prescriptions for children and youth within these drug classes will not be subject to PA reinstatement.1
- Note: Medi-Cal Rx product-specific coverage criteria for enteral nutrition products and medical supplies products have not changed or been waived. For prescriptions requiring a PA that do not have an approved PA (or a historical claim) on file, PA requirements will remain in place.1
For details, refer to “Update: Implementation of Phase I, Wave III – Reinstatement of Prior Authorizations for 11 Drug Classes” on the Medi-Cal Rx website > Education & Outreach > Bulletins & News.
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
1 Information derived or taken from Update: Implementation of Phase I, Wave III – Reinstatement of Prior Authorizations for 11 Drug Classes.