Medi-Cal Pharmacy (Rx) Update – Rejection Code 816
|December 1, 2022
|Health Plan of San Joaquin (HPSJ) Practitioners and Facilities
|Health Plan of San Joaquin (HPSJ)
|Medi-Cal Pharmacy (Rx) Update – REJECTION CODE 816
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). Medi-Cal Rx and HPSJ may request providers to bill specific injectable medications to Medi-Cal Rx. The Medi-Cal Rx Provider Manual also (https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-and-information/manuals/Medi-Cal_Rx_Provider_Manual.pdf) provides further details of medications and DME covered by Medi-Cal Rx.
In the event that a dispensing pharmacy obtains a “Reject Code 816 – Pharmacy Drug Benefit Exclusion” notification when billing to Medi-Cal Rx, the pharmacy or provider may submit a PA request to Medi-Cal Rx for consideration of an exception to bill the drug through the pharmacy benefit. If Medi-Cal Rx continues to deny coverage through the pharmacy benefit, consideration by the provider should be made to submit a PA to HPSJ for consideration of coverage under the medical benefit.
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 and on page two of this notice.
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 then 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 Medi-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 – 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)
|Specialty Pharmacy (e.g. Accredo, Diplomat, Optum, US Bioservices) mailing to the patient or to the provider’s office on behalf of the patient
|Long-term-care pharmacy is filling the medication and sending it to the Skilled Nursing Facility
|Provider or Facility already purchased and has the medication in their office/facility with plans for infusion or injection at their office/facility
|Outpatient infusion center using medications from within their internal stock and planning for infusions at their site
For any further 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.
You can also contact your Provider Services Representative or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit www.hpsj.com/alerts for online access to the documents shared.