Medi-Cal Rx Reinstatement: A Phased Approach - Shared screen with speaker view
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Re: covermymeds, if we try to submit a PA for a brand medication but generic is on formulary, we get a message that the medication is covered and we cannot submit the PA, even though we have brand entered and the NDC list says it needs a PA. Is this error being looking in to?
I thought CovermyMeds was only to use while transitioning to Magellen?
Once PA is approved does CMMs directly transfer medication to a specialty pharmacy?
will the prior authorization criteria be made public so providers can understand prior to submitting the PA?
Can CMM send mgmt. reports for an organization; eg. utilization pattern, high cost meds, approvals, denials, turn around time, etc.
Do you know what % of California Specialty Pharmacies use CMMs?
Hi Jason, Our top submitting prescribers use CMM; our top submitting pharmacies use Medi-Cal Rx Portal. Both provider types use fax. P4 is very rarely used by pharmacies.
If a prescribers sends in an rx for an immunization, can the pharmacy bill MediCalRx and the pt take it to their provider for the injection?
Hi Sommer, No. CoverMyMeds is the preferred method for prescribers to submit a PA
Do we need to use Magellen at all then?
If a pharmacy is set up with Cover My Meds, but the doctor is not, can the pharmacy submit a PA on behalf of the physician?
I could not see the whole list of 11 drug classes that will require PA in P1W3. Will opioids require a PA in this wave, and if so, what are the PA requirements?
What date does the reinstatement of PA for certain drug classes (diuretics, antihypertensive, etc.) go live?
Are the NDCs for formulary medications going to be expanded? Some pharmacies have restriction on what they can order from their vendor.
Hi Nicholas, here is the link to the 11 drug classes https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/bulletins/2022.08_A_30-Day_Countdown_Reinstatement_Limited_PA.pdf
We keep getting denials through CMM for injectables and intrauterine devices. Do we speak to customer service for that?
Hi Anna, Yes.
Hi Becca, 9/16/22
What steps are being taken to address issues with PAs for transgender patients?
For more info on PADs https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/bulletins/2022.03_A_Medi-Cal_Rx_Billing_Policy_for_PADs.pdf
At provider level how will we know that the NDC was the issue not the med itself?
what happens if a decision is not made on a PA within the 24 hour timeframe? Will it be auto approved?
will the medical groups who hold the risk for injectable drugs continue to have responsibility for that drug or will it need to go through Medi-Cal Rx?
Clarification on my previous question......Our clinic is not set up for Medi-Cal billing, but the pharmacy is AND we are in the same building. If the prescriber sends the pharmacy a prescription for Gardasil-9 or flu shot, for example, can the pharmacy bill for the shot, but have it administered by a nurse or prescriber at the clinic?
Apologies, double muted! Yes, we'll take that back to the Department.
Does the CMM system block pharmacies from submitting a PA? If not, does the pharmacy need to provide specific documentation to indicate they are submitting on the behalf of the prescriber since pharmacies are only allowed to initiate but not submit PA on CMM?
Yes, that is the question. Pharmacy doesn't always tell us what the issue is.
yes you are understanding my question correctly
If you can check what NDC your EMR sent out, you can check the Covered NDC list online.
Can you submit appeals on CMM?
I am not sure if it was answered or mentioned. But would we ever receive the approval letters for the PA's submitted via CMM.I have only been receiving the denials but nothing on approvals since the beginning of the year.
PAD Alert https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/bulletins/2022.03_A_Medi-Cal_Rx_Billing_Policy_for_PADs.pdf
Can someone clarify the statement "Pharmacy cannot submit a PA on behalf of the prescriber, but pharmacy can initiate it?"
Follow up to the appeal question - is there a separate function on the MediCal Rx portal to submit an appeal, or do we just resubmit a regular PA with additional info addressing the denial reasons?
Receive emails that say CMM has an update on a PA req, but no additional info is given?
sorry if I missed this but will the slides be posted on the MediCal Rx Education and Outreach webpage?
Hi Phu, only prescribers can submit (turn it in) a PA based on the clinical criteria. CoverMyMeds allows pharmacists to initiate (start it) a PA on behalf of the prescriber. The prescriber would then need to complete and submit the PA
Not sure if you can address this as it relates to Medi-Cal as a medical benefit and not MediCal RX. If you apply to be a Medi-Cal Provider, is it true the clinic has to be open to the public? What happens in the case for student health centers where services are strictly for students?
Hi Paul, yes the slide deck is available on the Medi-Cal Rx E&O page https://youtu.be/cVDAhFENBss
Hi Anna, for that question you would need to contact DHCS Pharmacy Enrollment Division
Jason, the pharmacy is enrolled, but not the clinic. Is it still the same dept?
Can we get a transcription of the chat thread?
thanks the link is to the video with a YouTube link but would appreciate a PDF version.
For Type II Diabetes, is CGM becoming a DME benefit administered by/approval through CHME, CA Home Medical Equipment?
I am a bit confused about diabetic testing supplies, is there a specific part of the website that addresses this?
With the new PA reinstatement coming 9/16, what will happen to patients seen in the emergency room for hypertensive emergency and started on new diuretics or antihypertensives? Will there be any workarounds so they can get their medications quickly? I do not see ED providers completing prior auths and often PCP is not aware they are in the ED immediately.
I am looking at Forms and Information page I don't see the obvious answer re testing supplies.
never mind, found the link, looks like there is a spreadsheet.
Samantha Fink, Medi-Cal Rx
under forms and information, click on "Covered Product Lists" on the left hand navigation https://medi-calrx.dhcs.ca.gov/provider/forms
Hi Paul, on the left hand menu click on covered products list
Are alll new starts for all diuretics & hypertensives require PA?
or only thosr not covered?
Hi Sahar, and see the alert https://youtu.be/cVDAhFENBss