Provider Alerts

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 (HPSJ). HPSJ may request providers to bill specific injectable medications to Medi-Cal Rx. The Medi-Cal Rx Provider Manual provides further details of medications and DME covered by Medi-Cal Rx. (https://medicalrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-andinformation/manuals/Medi-Cal_Rx_Provider_Manual.pdf)

Methods to distinguish whether a medication would be billed through the Pharmacy Benefit (billed to Medi-Cal Rx), or the Medical Benefit (billed to HPSJ) are listed below.

Pharmacy Benefit – Medication is processed through a Pharmacy Benefit Manager (PBM) at a dispensing pharmacy location. This applies to the following sample pharmacy types: retail, specialty, long-term-care, mail-order, compounding, etc. If a PA is required, visit
https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/bulletins/2022.01_A_PA_Submission_Reminders.pdf for various methods to send a PA to Med-Cal Rx.

Medical Benefit – Medication is already currently in stock at the provider’s office (buyand-bill) or within the facility administering the medication (e.g. outpatient infusion centers). If a PA is required then send a Medical Authorization form to HPSJ – https://www.hpsj.com/wp-content/uploads/2017/07/Medical-Authorization-7_17-updated.pdf.

	Pharmacy Benefit (Medi-Cal Rx)	Medical Benefit (HPSJ)
All Retail Pharmacies (e.g. CVS, Walgreens, independent pharmacy)	Yes	No
Specialty Pharmacy (e.g. Accredo, Diplomat, Optum, US Bioservices) mailing to the patient or to the provider’s office on behalf of the patient	Yes	No
Long-term-care pharmacy is filling the medication and sending it to the Skilled Nursing Facility	Yes	No
Provider or Facility already purchased and has the medication in their office/facility with plans for infusion or injection at their office/facility	No	Yes
Outpatient infusion center using medications from within their internal stock and planning for infusions at their site	No	Yes

For additional questions that Medi-Cal Rx is unable to assist in resolving, please contact the HPSJ Pharmacy Department at 209.461.2212 to leave a secure voicemail that will be returned within one business day.