REMINDER – Medi-Cal Rx Emergency Fill Prescriptions
| Date: | July 30, 2025 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Practitioners, Facilities and Hospitals |
| Type: | Event |
| Subject: | REMINDER – Medi-Cal Rx Emergency Fill Prescriptions |
| Business: | Medi-Cal Managed Care |
A reminder to all Medi-Cal providers dispensing of a 14-day emergency supply of all products that are Medi-Cal Rx benefits is permitted when delays in access to therapy due to utilization management claim edits would withhold a medically necessary service. Pharmacy Emergency Dispensing is exempt from prior authorization (PA) request or Code I requirements as stated in Section 15.7 of the Medi-Cal Rx Provider Manual linked here: https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/forms-and-information/manuals/Medi-Cal_Rx_Provider_Manual.pdf
Medi-Cal Rx reviews initial PA request submissions within 24 hours. However, delays in claim approval may occur when additional information is required to justify medical necessity or the PA request is denied and requires an appeal. DHCS recognizes there are circumstances in which an emergency fill is appropriate. If a Medi-Cal member experiences difficulty in obtaining a medically necessary medication or pharmacy product, and there is emergent need, an emergency fill for up to a 14-day supply may be requested by the member or an authorized health care team member. The pharmacy is responsible to self-certify that the emergency existed in accordance with CCR, Title 22, Section 51056(c).
If a pharmacy denies a request for an emergency fill, the Medi-Cal Rx Customer Service Center (CSC) is available to assist. Information about the member, prescription requested, and pharmacy will be needed by the CSC to investigate and support appropriate requests. The CSC is available at 1-800-977-2273, 24-hours a day, 7 days a week.
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
