Zoom Logo

Medi-Cal Rx Reinstatement: A Phased Approach - Shared screen with speaker view
Elizabeth Oseguera
If you have any questions please type them into the chat box :)
Becca Woodward
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?
Sommer Kaskowitz
I thought CovermyMeds was only to use while transitioning to Magellen?
Jason Murillo
Once PA is approved does CMMs directly transfer medication to a specialty pharmacy?
Johanna Liu
will the prior authorization criteria be made public so providers can understand prior to submitting the PA?
Susan Park
Can CMM send mgmt. reports for an organization; eg. utilization pattern, high cost meds, approvals, denials, turn around time, etc.
Jason Murillo
Do you know what % of California Specialty Pharmacies use CMMs?
Jason Manviller
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.
Anna Chaparyan
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?
Jason Manviller
Hi Sommer, No. CoverMyMeds is the preferred method for prescribers to submit a PA
Sommer Kaskowitz
Do we need to use Magellen at all then?
Anna Chaparyan
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?
Nicholas Hutchings
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?
Becca Woodward
What date does the reinstatement of PA for certain drug classes (diuretics, antihypertensive, etc.) go live?
Dulce Landazuri
Are the NDCs for formulary medications going to be expanded? Some pharmacies have restriction on what they can order from their vendor.
Jason Manviller
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
Teresa Ibanez
We keep getting denials through CMM for injectables and intrauterine devices. Do we speak to customer service for that?
Jason Manviller
Hi Anna, Yes.
Jason Manviller
Hi Becca, 9/16/22
Nicholas Hutchings
What steps are being taken to address issues with PAs for transgender patients?
Jason Manviller
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
Paul Bayard
At provider level how will we know that the NDC was the issue not the med itself?
Johanna Liu
what happens if a decision is not made on a PA within the 24 hour timeframe? Will it be auto approved?
Jason Murillo
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?
Jason Manviller
Anna Chaparyan
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?
Julie Cheung
Apologies, double muted! Yes, we'll take that back to the Department.
stan leung
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?
Paul Bayard
Yes, that is the question. Pharmacy doesn't always tell us what the issue is.
Paul Bayard
yes you are understanding my question correctly
Becca Woodward
If you can check what NDC your EMR sent out, you can check the Covered NDC list online.
Lanell Warner
Can you submit appeals on CMM?
Ashley Gudiel
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.
Jason Manviller
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
Phu To
Can someone clarify the statement "Pharmacy cannot submit a PA on behalf of the prescriber, but pharmacy can initiate it?"
Nicholas Hutchings
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?
Sahar Naz
Receive emails that say CMM has an update on a PA req, but no additional info is given?
Paul Bayard
sorry if I missed this but will the slides be posted on the MediCal Rx Education and Outreach webpage?
Jason Manviller
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
Anna Chaparyan
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?
Jason Manviller
Hi Paul, yes the slide deck is available on the Medi-Cal Rx E&O page https://youtu.be/cVDAhFENBss
Jason Manviller
Hi Anna, for that question you would need to contact DHCS Pharmacy Enrollment Division
Anna Chaparyan
Jason, the pharmacy is enrolled, but not the clinic. Is it still the same dept?
Bryan Tsao
Can we get a transcription of the chat thread?
Paul Bayard
thanks the link is to the video with a YouTube link but would appreciate a PDF version.
Susan Park
For Type II Diabetes, is CGM becoming a DME benefit administered by/approval through CHME, CA Home Medical Equipment?
Paul Bayard
I am a bit confused about diabetic testing supplies, is there a specific part of the website that addresses this?
Becca Woodward
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.
Paul Bayard
I am looking at Forms and Information page I don't see the obvious answer re testing supplies.
Paul Bayard
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
Jason Manviller
Hi Paul, on the left hand menu click on covered products list
Sahar Naz
Are alll new starts for all diuretics & hypertensives require PA?
Sahar Naz
or only thosr not covered?
Jason Manviller
Hi Sahar, and see the alert https://youtu.be/cVDAhFENBss