Medi-Cal Pharmacy (Rx) – DHCS APL 25-013 Medi-Cal Rx Pharmacy Benefits, And Cell and Gene Therapy Coverage
| Date: | October 29, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities, and Hospitals |
| Type: | Informational/Educational |
| Subject: | Medi-Cal Pharmacy (Rx) – DHCS APL 25-013 Medi-Cal Rx Pharmacy Benefits, And Cell and Gene Therapy Coverage |
| Business: | Medi-Cal Managed Care |
REMINDER: In accordance with Governor Gavin Newsome’s Executive Order N-01-19, outpatient pharmacy benefits were transitioned to Medi-Cal Rx on 1-1-2022. Due to the benefit transitioning, some medications are paid for by Medi-Cal Rx, and some are paid for by the Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan). Medi-Cal Rx and Health Plan may request providers to bill specific injectable medications to Medi-Cal Rx. The Medi-Cal Rx Provider Manual also provides further details of medications and durable medical equipment (DME) covered by Medi-Cal Rx.
Medi-Cal Rx Provider Manual: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-and-information/manuals/Medi-Cal_Rx_Provider_Manual.pdf
Cell and Gene Therapy Coverage
In March of 2025, Medi-Cal Rx was approved to participate in the federal Cell and Gene Therapy (CGT) Access Model by the Center of Medicare and Medicaid Services (CMS). The Model aims to improve and streamline access to two lifesaving CGT medications: LYFEGENIA and CASGEVY for Sickle Cell Disease (SCD). Under the Model, these medications are carved out from Health Plan coverage and covered by Medi-Cal Rx, while Health Plan remains responsible for all associated outpatient or inpatient medical services and non-medical ancillary services that support members through their SCD CGT treatments, such as the following:
(1) Transportation
(2) Claim payments for administration of the medication.
(3) Continuity of care from prior health plan.
(4) Ensure access to treatment centers.
(5) Other coverage that is associated with the services of the treatment.
Further details and resources can be found via the Medi-Cal Rx links below:
https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL%202025/APL25-013.pdf
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
