DHCS Medi-Cal Rx
DHCS HAS ANNOUNCED A JANUARY 1, 2022 IMPLEMENTATION DATE.
Register as a Prescriber today with Magellan to Be Ready for Medi-Cal Rx!
Magellan Medicaid Administration, Inc. (MMA) will assume 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)
IEHP and DHCS strongly recommends our Providers to visit the new Medi-Cal Rx website as soon as possible (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
- Review general information about the transition
Background Information:
On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 (EO-N-01-19) for achieving cost-savings for drug purchases made by the state. A key component of EO N-01-19 requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS).
Transitioning pharmacy services from MC to FFS will, among other things:
- Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system.
- Improve access to pharmacy services with a pharmacy network that includes approximately 94% of the state’s pharmacies.
- Apply statewide utilization management protocols to all outpatient drugs.
- Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.
- And more!
The Medi-Cal pharmacy benefits and services administered by DHCS in the FFS delivery system will be identified collectively as “Medi-Cal Rx”.
- Medi-Cal Rx 101 Webinar Presentation (PDF) - September 17, 2021
Communication from IEHP
- December 22, 2021 - Medi-Cal Rx Transition - Blood Pressure Monitors and Nebulizers (PDF)
- December 22, 2021 - CalAIM Expansion to Zip Codes now in IEHP’s Service Area – January 1, 2022 (PDF)
- December 17, 2021 - DHCS Medi-Cal Rx (Carve Out) and Members’ Preferred Pharmacy (PDF)
- December 10, 2021 - REMINDER - Medi-Cal Rx Launches January 1, 2022! (PDF)
- November 30, 2021 - Medi-Cal Rx to Launch January 1, 2022! (PDF)
- October 26, 2021 - DHCS 60-Day Advance Notice to IEHP Members about Medi-Cal Rx (PDF)
- September 07, 2021 - IMPORTANT UPDATE: Medi-Cal Rx Implementation on January 1, 2022. Register for the Medi-Cal Rx Provider Portal Today! (PDF)
- November 19, 2020 - Important - Medi-Cal Rx Transition Implementation Delay to April 1, 2021 (PDF)
- October 23, 2020 - Medi-Cal Rx - Transition of Medi-Cal Pharmacy Administration Services to Magellan Medicaid Administration, Inc. (PDF)
- October 08, 2020 - Medi-Cal Rx Program – Register Today as a Prescriber (PDF)
Communication from DHCS
- January 09, 2022 - Prior Authorization Required - Reject Code 75 (PDF)
- January 07, 2022 - Pharmacy Claims Reject Code 65 - Resolved (PDF)
- December 06, 2021 - APL 21-018: Governor's EO N-01-19, Regarding Transitioning Medi-Cal Pharmacy Benefits from Managed Care to Medi-Cal Rx (PDF)
- December 06, 2021 - Medi-Cal Rx Web Claims Submission User Guide Now Available (PDF)
- December 03, 2021 - CoverMyMeds Registration (PDF)
- December 01, 2021 - Medi-Cal Rx Monthly Bulletin - December (PDF)
- November 18, 2021 - UAC Registration and Sign-In Troubleshooting (PDF)
- November 09, 2021 - Introducing the Medi-Cal Rx Education & Outreach Team (PDF)
- November 04, 2021 - Pharmacy Training Checklist (PDF)
- November 04, 2021 - Prescriber Training Checklist (PDF)
- November 03, 2021 - Join the Medi-Cal Rx Provider Portal Today (PDF)
- July 30, 2021 - Medi-Cal Rx Frequently Asked Questions (FAQs) (PDF)
- October 22, 2020 - DHCS (Medi-Cal Rx) – NCPDP Standard Payer Sheet, Version 1.0 (PDF)
- October 21, 2020 - Medi-Cal Rx Prescribers Communication (PDF)
- October 16, 2020 - Medi-Cal Rx Web Portal Registration & Training Update (PDF)
- October 01, 2020 - Medi-Cal Rx Transition of Medi-Cal Pharmacy Administration Services to Magellan Medicaid Administration, Inc. (PDF)
Please refer to the DHCS Medi-Cal Rx: Transition for additional information.
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.
- What is a Biosimilar? (PDF)
- Biological Product Definitions (PDF)
- Prescribing Biosimilar Products (PDF)
- Prescribing Interchangeable Products (PDF)
Opioid and Chronic Pain Management
In collaboration with Riverside University Health System (RUHS) and Centers for Disease Control and Prevention (CDC), IEHP would like to provide the following information to assist you and your practice on prescribing opioids for chronic pain management.
CURES
- CURES FAQ (PDF)
- CURES 2.0 User Guide (PDF)
- CURES tips and tricks (PDF)
- Naxolone Drug facts (PDF)
- Naxolone instructions for use (PDF)
- First Responder Naxolone administration fact sheet (PDF)
Opioid Prescribing Guidelines
- Medication Assisted Treatment (MAT) and Opioid Treatment Program (OTP) FAQ (PDF)
- CDC Guideline Infographic (PDF)
- CDC Guidelines Factsheet (PDF)
- TurnTheTide Pocket Guide for Prescribing Opioids for Chronic Pain (PDF)
Opioid Tapering
- Clinical Pocket Guide to Tapering (PDF)
- Tapering Resource-AAFP (PDF)
- Opioid Tapering Resource pack (PDF)
Pharmacy
Urine Drug Testing
X-Waiver
- X-Waiver resources
- Quick information about DATA 2000
- X-waiver online form
- For more information, contact SAMHSA:
- (866) BUP-CSAT (866-287-2728)
- infobuprenorphine@samhsa.hhs.gov
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
- Medicare FAQ (PDF)
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 Cal MediConnect Plan (Medicare-Medicaid Plan)
What is IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)?
IEHP DualChoice is a Cal MediConnect Plan. A Cal MediConnect Plan 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?
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 integrates healthcare services to better coordinate care and improve health.
How to Enroll
To enroll, please call:
- IEHP DualChoice Medicare 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 website. You may also call IEHP DualChoice 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 Cal MediConnect Plan (Medicare-Medicaid Plan) 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 October 15, 2018.
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.
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:
- IEHP Medi-Cal Floor Stock List (PDF)
- DHCS Noncapitated Physician Administered Drugs (PADs)
- Medi-Cal Medical Benefit PA_July 2022 (effective 7/1/2022)
- Medi-Cal Medical Benefit Formulary_July 2022 (effective 7/1/2022)
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 Cal MediConnect (Medicare-Medicaid Plan) Items:
- DualChoice Cal MediConnect Formulary Book (PDF)
- Grievance Coverage Determination and Appeals Process
- DualChoice Cal MediConnect Formulary Search Tool
- IEHP DualChoice Cal MediConnect Formulary Maintenance Drug List (PDF)
- 10 Reasons Why You Should Be E-prescribing Brochure (PDF)
- E-prescribing Tips (PDF)
Information on this page is current as of April 1, 2022
Pharmacy Forms and Manuals
Prior Authorization/Coverage Determination
- Request for Medicare Prescription Drug Coverage Determination - For Medicare DualChoice and Medicare DualChoice Cal MediConnect Plans - English (PDF)
- Request for Medicare Prescription Drug Coverage Determination - For Medicare DualChoice and Medicare DualChoice Cal MediConnect Plans - Spanish (PDF)
- Request for Redetermination of Medicare Prescription Drug Denial - English (PDF)
- Request for Redetermination of Medicare Prescription Drug Denial - Spanish (PDF)
Drug Request
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
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)
- Pain Assessment and Treatment Plan 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 March 31, 2022.
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.
Information on this page is current as of May 10, 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).
The rating is on a scale of 1 to 5 stars (with 1 being the lowest and 5 being the highest).
| Star Ratings |
Performance Description |
|---|---|
| 1 Star |
Well below average |
| 2 Stars |
Below average |
| 3 Stars |
Average |
| 4 Stars |
Good |
| 5 Stars |
Exceptional |
| No Star |
No information is available for this pharmacy |
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: