(*80*)
July 21, 2022
Area(s) of Interest: Payor Issues and Reimbursement Public Payors
The California Department of Health Care Services (DHCS) has elected to postpone implementation of Medi-Cal Rx Reject Code 80, regardless of just lately saying it could be included within the first of three phases to reinstate pharmacy declare edits and prior authorization necessities for prescribed drugs. Drug Utilization (*88*) edits (DUR 88) will take impact July 22, 2022, as beforehand introduced.
Earlier this yr the DHCS started waiving prior authorizations from the Medi-Cal Rx program, retroactive to January 1, 2022, to attenuate disruptions in affected person entry to prescription medicines that occurred on account of challenges with the Medi-Cal Rx transition.
In the primary of the three phases, declare edits for Drug Utilization (*88*) edits will probably be turned on efficient July 22, 2022. DUR Reject Code 88 alerts are triggered by situations corresponding to drug-drug interactions, excessive dose, early refills, and so forth.
DHCS has resolve to additional delay implementation of Reject Code 80 (Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria) on account of stakeholder suggestions that implementation of Reject Code 80 might necessitate submission of prior authorizations previous to the timeframe focused for prior authorization reinstatement, which might intrude with the supply of well timed and protected pharmacy providers to Medi-Cal beneficiaries.
Although claims submitted to Medi-Cal Rx is not going to be edited for a analysis code, DHCS is reminding suppliers of their obligation to fulfill and doc Code 1 restrictions and to maintain that information available.
It is unclear when Reject Code 80 will probably be turned again on. However, DHCS has beforehand indicated that someday in August, the next drug lessons will once more require prior authorization:
- Diuretics
- Lipotropics, together with statins and omega‐3 fatty acids
- Hypoglycemics, together with glucagon
- Coronary vasodilators (nitrates and pulmonary arterial hypertension brokers)
- Cardiovascular brokers, together with antiarrhythmics and inotropes
- Anticoagulants and antiplatelets
- Niacin, Vitamin B, and Vitamin C merchandise
Stay updated with the newest Medi-Cal Rx news by signing up for the Medi-Cal Rx Subscription Service. For questions, please contact the Medi-Cal Rx Customer Service Center at (800) 977-2273, obtainable 24 hours a day, one year a yr, or e-mail [email protected].