IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization List

IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization List

The IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization List is a continually updated list of drug products designed to reflect the most appropriate, high quality and cost-effective drug therapies.

 

The Inland Empire Health Plan Pharmacy and Therapeutics (P&T) Subcommittee develops and monitors the IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization List. The P&T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, Physicians from various medical specialties, local communities, and Clinical Pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.  The Subcommittee also ensures that the IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization List remains responsive to the needs of our Members and Providers.

IEHP Physician Administered Drug (PAD) Prior Authorization

IEHP Medi-Cal Physician Administered Drug (PAD) Prior Authorization Items

Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit.

Additional Drug Prior Authorization Criteria

 
TitleEffective Date
Synagis (PDF)September 1, 2023
Zynteglo (PDF)June 1, 2024
Erythropoiesis Stimulating Agents (PDF)September 1, 2023
Immuno Globulins (PDF)December 1, 2023

Starting January 1, 2022, all IEHP Medi-Cal pharmacy services had been transitioned to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS), which is identified collectively as "Medi-Cal Rx."  As a reminder, below DHCS articles provide guidance on how to bill Physician Administered Drugs (PADs).

DHCS Medi-Cal Rx (Medi-Cal Pharmacy Benefit)

On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 for achieving cost-savings for drug purchases made by the state. A key component of the Executive Order requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care to fee for service (FFS).  More information about “Medi-Cal Rx: Transition” can be found on DHCS website.

 

Updated April 7, 2021, “Medi-Cal Rx Pharmacy Transition Policy”  describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan had provided system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx.

 

Effective January 1, 2022, the Medi-Cal pharmacy benefits and services are administered by DHCS in the Fee-For-Service (FFS) delivery system, known as "Medi-Cal Rx."  Magellan Medicaid Administration, Inc. (MMA) has assumed operations for Medi-Cal Rx on behalf of DHCS.  For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl

 

IEHP and DHCS strongly recommends our Providers to visit the new Medi-Cal Rx website (https://medi-calrx.dhcs.ca.gov) to register for the Magellan Medi-Cal Rx portal, review schedule of trainings available on the new Medi-Cal Rx Portal, and review general information about the transition.

Communication from DHCS

 

Please refer to the DHCS Medi-Cal Rx: Bulletins & News page for additional information.

 

Communication from IEHP

 

Please refer to IEHP’s Provider notices and IEHP’s Pharmacy Provider notices pages for additional information.

 

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