DHCS Medi-Cal Rx 

Register as a Prescriber today with Magellan to Be Ready for 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) assumes operations for Medi-Cal Rx on behalf of the State of California Department of Health Care Services (DHCS).

• How to Register for the User Administration Console (UAC) (PDF)
• User Administration Console (UAC) Quick Start Guide (PDF)
• Medi-Cal Rx 101 Webinar Presentation (PDF)

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: Transition and DHCS Medi-Cal Provider Pharmacy News Bulletins pages for additional information.

Communication from IEHP

While you can always refer to Pharmacy Communication and Provider Correspondence pages, the below list is provided for your convenience.

• January 02, 2023 - IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance (PDF)
• December 22, 2022 - Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition (PDF)
• October 28, 2022 - Cal MediConnect to Medi-Cal RX Transition (D-SNP) (PDF)
• July 29, 2022 - NEW DATE: Medi-Cal RX Gradual Reinstatement of Prior Auths (PAs) – Phase 1 – September 16, 2022 (PDF)
• July 13, 2022 - DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80 (PDF)
• July 11, 2022 - Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1 (PDF)
• June 03, 2022 - Medi-Cal RX Transition: Blood Pressure Monitors and Cuffs (PDF)
• June 03, 2022 - Medi-Cal RX Billing Policy for Physician Administered Drugs (PADs) (PDF)
• February 17, 2022 - RETRACTION - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM - PCP) (PDF)
• February 17, 2022 - RETRACTION - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM - IPA)  (PDF)
• February 14, 2022 - Medi-Cal Rx Transition Survey - Your Response is Important! (PDF)
• February 11, 2022 - Updated - Medi-Cal Rx Transition - Implantable and Injectable Contraceptives FAQs (PDF)
• February 09, 2022 - Medi-Cal Rx Transition - Hyaluronic Acid Knee Injections (PDF)
• February 07, 2022 - Medi-Cal Rx UPDATE: Revised Prior Auth Policy for Prescribers and Emergency Fill Quantity Limit (PDF)
• February 07, 2022 - Medi-Cal Rx Transition - How To Assist IEHP Members (PDF)
• January 18, 2022 - Medi-Cal Rx Transition - Implantable and Injectable Contraceptives (PDF)
• January 18, 2022 - Medi-Cal Rx (Magellan) Customer Service (PDF)
• January 18, 2022 - Medi-Cal Rx Transition - Continuous Glucose Monitors (CGM) (PDF)
• January 04, 2022 - CORRECTION! Medi-Cal Rx: Mail Order for Blood Pressure Monitors and Nebulizers (PDF)

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Academic Detailing

The IEHP Pharmacy Academic Detailing team is an educational and evidence-based outreach program for our providers and pharmacies. We perform phone and one-on-one outreaches with physicians, nurse practitioners, physician assistants, and pharmacy staff. Our goal is to transform the prescriber and pharmacy practice and enhance the provider, pharmacist and member experience.

Clinical Drug Education

Clinical Drug Education provides materials that focus on a specific drug, drug class, and/or disease state. These materials contain pharmacological and clinical practice information to assist providers and pharmacies in their practice. As new drug information is available, it is important to stay up to date on clinical research findings to assist with member care and medication-use decisions.

Biosimilars

A growing trend in healthcare is the use of biosimilar drugs. The following information will assist you and your practice on prescribing biosimilars.

Practice Optimization

Electronic Prescribing (e-Rx)

Electronic prescribing is a growing standard in the healthcare industry. Most electronic health record systems offer electronic prescription capabilities. The information below will provide insight to the practice of e-prescribing.

Formulary Utilization

The IEHP Formulary offers a variety of drugs based on safety and efficacy for any condition. The information below will help you find out how to access and interpret the formulary

The process of submitting a prior authorization may be cumbersome for your practice. The information below will help you understand this process and assist with receiving a proper decision in a timely manner.

For any questions regarding Pharmacy Academic Detailing Training please contact:

PharmacyAcademicDetailing@iehp.org

Information on this page is current as of January 1. 2022

IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan

What is IEHP DualChoice (HMO D-SNP) Plan?
IEHP DualChoice (HMO D-SNP) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. It is an organization made up of doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. It also has care coordinators and care teams to help you manage all your providers and services. They all work together to provide the care you need.

What is the goal of this program?
The goal is to improve care by integrating the following healthcare services:

• Medicare and Medi-Cal benefits
• Long-term care
• Behavioral health
• Home and community-based services (HCBS) such as Community-Based Adult Services (CBAS) and Multipurpose Senior Services Program (MSSP).

Who is eligible for IEHP DualChoice (HMO D-SNP)?
People who have both Medicare and Medi-Cal. For a complete list of who is included or excluded, visit Who Qualifies?

Plans and Benefits
IEHP DualChoice (HMO D-SNP) integrates healthcare services to better coordinate care and improve health.

How to Enroll

To enroll, please call:

• IEHP DualChoice (HMO D-SNP) Team at 1-800-741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347, OR
• Health Care Options (HCO) at 1-844-580-7272, 8am – 5pm (PST), Monday – Friday. TTY/TDD users should call 1-800-430-7077.

For more information, visit the DHCS website. By clicking on this link, you will be leaving the IEHP DualChoice (HMO D-SNP) website. You may also call IEHP DualChoice (HMO D-SNP) for help at 1-877-273-IEHP (4347), 8am – 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347 (4347).

• Plan Benefits and Cost-Sharing: Find out about plan benefits which are the types of medical care that are covered. Also view information on cost-sharing which is how much you will pay for services or prescription drugs, including monthly plan premium and co-payment.
• Part D Prescription Drugs: Get information on pharmacy benefits, IEHP network pharmacies, out-of-network coverage, pharmacy transition process, drug utilization management, and prescription mail order.
• Provider Access Information: Learn about network providers, primary care providers, specialists and how to choose a provider in our network. Read about our quality assurance activities and find out what happens if your doctor leaves our plan.
• Grievances, Coverage Determination and Appeals Process: Find out what to do if you have a problem or complaint about your medical care or Part D.
• Helpful Information: View your rights and responsibilities upon disenrollment and as a Member of IEHP. You will also find important forms for 2018 such as our Privacy Notice, Plan Transition Process and the section of CMS' website regarding Best Available Evidence.
• Service Area: Find out which zip codes in Riverside and San Bernardino counties are included in our service area. 

IEHP DualChoice (HMO D-SNP) is a Health Plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Information on this page is current as of December 29, 2022.
H5355_CMC_19_1059755 Accepted      

Clinical Information

Go to Clinical Information Page. In this section find these resources that include printable reference documents for your convenience and ease of use.

Go to the Quality & Clinical Resources and Tools page. In this section find information regarding Clinical Practice Guidelines.

• Safety Resources

Maximum Allowable Charges (MAC)

DST Pharmacy Solutions maintains the Maximum Allowable Cost (MAC) drug list and addresses MAC appeals for IEHP’s Medicare Line of Business.  Please direct all MAC appeals, regardless of fill date, via email to m5@dsthealth.com; or direct MAC appeals over the phone to DST Pharmacy Solutions at 1-800-522-7487, Monday through Friday, 8:00AM – 5:00PM CST (6:00AM – 3:00PM PST).

Click here for more information about previous IEHP MAC Drug Lists and MAC appeals processing.

Information on this page is current as of December 20, 2021

Formulary

The IEHP Formulary 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 Formulary. 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.

Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.

IEHP Medi-Cal Formulary Items:

• DHCS Noncapitated Physician Administered Drugs (PADs)
• Medi-Cal Medical Benefit PA (PDF)
• Medi-Cal Medical Benefit Formulary (PDF)
• Referral Form for Medi-Cal Benefit (PDF)

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.

Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx."

Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS.

For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx

For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl

IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items:

• IEHP DualChoice (HMO D-SNP) Formulary Book(PDF)
• Grievance Coverage Determination and Appeals Process
• IEHP DualChoice (HMO D-SNP) Formulary Search Tool       
• 10 Reasons Why You Should Be E-prescribing Brochure (PDF)
• E-prescribing Tips (PDF)

Information on this page is current as of March 01, 2023

Pharmacy Forms and Manuals

Coverage Redetermination  

MedImpact (IEHP Medicare Line of Business's PBM) handles all Medicare pharmacy and provider prior authorization and pharmacy benefit related questions. Providers and pharmacies can call MedImpact Customer Contact Center at (800) 788-2949. Health care providers can submit prior authorizations via fax (858) 790-7100, or download forms at the MedImpact Website.

• Request for Redetermination of Medicare Prescription Drug Denial - English (PDF)
• Request for Redetermination of Medicare Prescription Drug Denial - Spanish (PDF)
• Coverage Determination Form - Retroactive prior authorization requests (PA requests dated before 1/1/2023) should be faxed to (909) 890-5766.
 

Drug Request

• Supplemental PER Form for Compounded Prescription (PDF)

Medicare

• Hospice Form for Medicare Part D Plans (PDF)
• Medicare Prescription Drug Coverage and Your Rights - English (PDF)
• Medicare Prescription Drug Coverage and Your Rights - Spanish (PDF)

Mail Order

• Mail-Order Service Fax Form (PDF)

Other Pharmacy Provider Forms

• Appointment of Representative - English (PDF)
• Appointment of Representative - Spanish (PDF)
• Nutritional Evaluation Form - Adult (PDF)
• Nutritional Evaluation Form - Infant (PDF) 
• Opioid Edit Error Report Form (PDF)

WIC Program Forms (California Department of Public Health)

• Pediatric Referral Form (PDF)
• WIC Referral For Pregnant Women (PDF)
• WIC Referral For Postpartum/Breastfeeding Women (PDF)

 

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.

 

Information on this page is current as of January 05, 2023.

Pharmacy Network Lists

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.

To view IEHP’s current Pharmacy Network under IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan, please use this link:

• Under “How to Access Care” tab, click on “2022 IEHP DualChoice Provider and Pharmacy Directory (PDF)".

 

To view IEHP’s future Pharmacy Network under IEHP DualChoice (HMO D-SNP), please use this link:

• Under “How to Access Care” tab, click on “2023 IEHP DualChoice Provider and Pharmacy Directory (PDF)".

Information on this page is current as of November 02, 2022.

Pharmacy Quality Star Ratings

What is Pharmacy Quality Rating?

IEHP Pharmacy Quality Rating is created to help IEHP Members to find high-quality local pharmacies for your pharmacy services. This searchable system will display the rating of each participating pharmacy. The ratings range from 1 to 5 stars (with 1 being the lowest and 5 being the highest).

Please keep in mind that Pharmacy Quality Star Rating is currently under development and may not reflect the most recent ratings of your Pharmacy at this time.
IEHP Pharmacy Quality Rating is visible with IEHP "Find a Doctor, Urgent Care, or Pharmacy" webpage (select “Pharmacies” and put in your zip code or city, then hit “Find”). The quality rating information is displayed on the right side of each pharmacy.

Provider Communications

IEHP Pharmaceutical Services serves a variety of provider communications notices from most recent P&T Formulary changes to current PER processing changes, and even CME event invitations.  The published notifications are grouped respectively for:

• Provider Communication - Pharmacy
• Provider Communication - Physician