Provider Alerts

Effective September 16, 2022, 11 Standard Therapeutic Classes (STC) will be reinstated with prior authorization (PA) requirements. The STC are:

• Diuretics
• Antilipemic agents (including statins and Omega-3 fatty acids)
• Hypoglycemics and glucagon
• Antihypertensives
• Coronary vasodilators (nitrates and pulmonary arterial hypertension agents)
• Cardiovascular agents (including antiarrhythmics and inotropes)
• Anticoagulants and antiplatelets
• Niacin, Vitamin B, and Vitamin C products

Further information regarding which NDCs and medications will contain PA requirements within the 11 STC as well as responses to frequently asked questions (FAQs) are available via https://medicalrx.dhcs.ca.gov/cms/medicalrx/staticassets/documents/provider/bulletins/2022.08_A_PhaseI_Wave3_PA_Submission_Reminder.pdf.

As a reminder, 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 (https://medi-calrx.dhcs.ca.gov/cms/medicalrx/staticassets/documents/provider/forms-and-information/manuals/Medi-Cal_Rx_Provider_Manual.pdf) also provides further details of medications and DME covered by Medi-Cal Rx.

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://medicalrx.dhcs.ca.gov/cms/medicalrx/staticassets/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 (buy-and-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

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You may contact our Customer Service Department with any questions or concerns, Monday through Friday, 8:00 am to 5:00 pm, at 1-888-936-PLAN (7526), TDD/TYY 711. Thank you for your continued support of Health Plan of San Joaquin. You may also visit https://www.hpsj.com/alerts/ for online access to this document and additional provider alerts previously shared. The most recent information about Health Plan of San Joaquin and our services is always available on our website https://www.hpsj.com/.