REMINDER – Medi-Cal Pharmacy (Rx) Update – Pediatric Integration
| Date: | January 08, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities, and Hospitals |
| Type: | Informational / Educational |
| Subject: | REMINDER – Medi-Cal Pharmacy (Rx) Update – Pediatric Integration |
| Business: | Medi-Cal Managed Care |
EFFECTIVE JANUARY 31, 2025, Medi-Cal Rx will reinstate claim edits and prior authorization (PA) requirements for members 21 years of age and younger.
This will apply to both new start and continuation of therapy claims.
Specific California Children’s Services (CCS) Panel Providers will have prescribing authority for a limited list of medications and supplies for the pediatric members with complex medical conditions that they care for. Per the CCS Panel Authority policy, CCS Panel Providers will be able to prescribe select drugs, enteral nutrition products, and medical supplies when the following conditions are met:
- The member is younger than 21 years of age.
- The prescription is written by a CCS Panel Provider who has been given CCS Panel Authority by the Department of Health Care Services (DHCS).
Further details and resources can be found via this Medi-Cal Rx Bulletin: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/publications/2024.12_A_30-Day_Countdown_Pediatric_Integration_Members.pdf
REMINDER: Outpatient pharmacy benefits were transitioned to Medi-Cal Rx on 1-1-2022. Due to the benefit transitioning, some medications are paid for by Medi-Cal Rx and some are paid for by the Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan). Medi-Cal Rx and Health Plan may request providers to bill specific injectable medications to Medi-Cal Rx. The Medi-Cal Rx Provider Manual also (https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-and-information/manuals/Medi-Cal_Rx_Provider_Manual.pdf) provides further details of medications and durable medical equipment (DME) covered by Medi-Cal Rx.
For any further questions that Medi-Cal Rx is unable to assist in resolving, please contact the Health Plan Pharmacy Department at 209.461.2212 to leave a secure voicemail that will be returned within one business day.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
