providers

Medi-Cal Rx Transition: Provider Guide

On January 1, 2022, outpatient pharmacy benefits for HPSM Medi-Cal members will transition from HPSM to fee-for-service (FFS) Medi-Cal. As of that date, these services will no longer be managed by HPSM. Instead, they will be administered by the California Department of Health Care Services (DHCS) in partnership with its contracted pharmacy benefits manager (PBM), Magellan. These pharmacy benefits will also be rebranded as “Medi-Cal Rx”. 

Medi-Cal Rx provider procedural changes are summarized below. These are the latest updates on the plan's drug list, authorization policies (including during the transition period) and billing processes.

Official DHCS Medi-Cal information & resources

Refer HPSM patients who have questions about Medi-Cal Rx to our online member guide

What’s changing (for Medi-Cal members only)

Formulary

Instead of a formulary, there is a preferred drug list called the Medi-Cal Rx “Contract Drug List” (CDL).

Refer to the Medi-Cal Rx Contract Drug List (CDL) instead of HPSM’s formulary to find the list of covered drugs for beneficiaries. Like a drug formulary, the CDL may change over time. A drug lookup tool will also be available.

Authorizations

You will need to submit pharmacy-benefit prior authorization (PA) requests to Magellan instead of HPSM

There are several instances when a PA is required before Medi-Cal will pay for a drug you are prescribing to a member:  

  • The drug is not on the Medi-Cal CDL
  • The drug is on the Medi-Cal CDL, but is flagged as requiring a PA
  • The drug is on the Medi-Cal CDL, but with restrictions exceeded by the prescription

Please keep in mind that under Medi-Cal Rx, PA requirements, review criteria and the process for handling authorization denials may differ from what HPSM has historically done.

Submit pharmacy PA requests to Magellan, the contracted PBM for DHCS. You can submit a PA request in any of the following four ways:

  1. By Medi-Cal Rx Secured Portal (sign-up required) 
  2. Electronically via CoverMyMeds
  3. By fax: 800-869-4325
  4. By mail:
    Medi-Cal Rx Customer Service Center
    Attn: PA Request
    P.O. Box Number 730
    Rancho Cordova, CA 95741-0730

Transition

Medi-Cal Rx will support the transition by honoring existing PA approvals from HPSM and allowing for a 180-day period where existing prescriptions will not require PA

During the transition, prescription coverage will depend on:

  • Existing prescription covered by PA Medi-Cal Rx will cover the prescription for the duration of the PA, not to exceed one year from the date the prescription was written (exceptions apply)
  • Existing prescription covered without a PA Medi-Cal Rx will continue covering for at least the first 180 days before requiring any PA
  • New prescription that requires PA under Medi-Cal Rx You will need to submit a PA
  • New prescription that does not require PA under Medi-Cal Rx No additional action needed

Billing

How pharmacies bill for prescriptions 

Starting on January 1, 2022, pharmacies are to bill Magellan instead of HPSM (or HPSM’s PBM, SS&C). To bill Magellan, pharmacies should use the following information:

  • Member ID: 9-digit CIN or 14-character BIC
  • BIN: 022659
  • PCN: 6334225
  • Group ID: MediCalRx

What’s staying the same

Medi-Cal Rx will not affect:

  • All other health care benefits currently managed by HPSM
  • Pharmacy benefits for HPSM CareAdvantage or HealthWorx patients (HPSM will continue to manage these)