Medi-Cal Rx Carve-Out

Effective Saturday, January 1, 2022, the Department of Health Care Services (DHCS) will manage the Medi-Cal pharmacy benefit instead of the Alliance. The new program will be called “Medi-Cal Rx”.

We have put together frequently asked questions (FAQs) to provide information on the change.

What is changing?

Starting Saturday, January 1, 2022, DHCS is working with a new contractor, Magellan Medicaid Administration, Inc. (Magellan) to provide Medi-Cal Rx services. The Alliance will no longer be the administrator for the pharmacy benefit after Saturday, January 1, 2022.

What do I need to do?

Most Alliance members will not need to do anything. DHCS will automatically transition from the existing administrator to Magellan on Saturday, January 1, 2022. Your doctors and pharmacies know about the change and know what to do. There is no change in your Medi-Cal eligibility or benefits.

What happens now?

Your access to your pharmacy benefits will not change. There will be no change in how you pay for your medications. For most Medi-Cal members there is no cost. Most people will be able to use the same pharmacy they do now on January 1, 2022. If your pharmacy does not work with Medi-Cal Rx, you may need to choose another pharmacy.

Will I need to change my medications?

Most Alliance members will not have any change in their medications. Some medications may need approval from Magellan before you can get them. For these medications, your doctor or pharmacy will have to fill out a form and get approval when you renew your prescription. Your doctor might also talk to you about changing to a similar medication that doesn’t need approval. Your doctor and pharmacy will know about this change.

Is the California Children’s Services (CCS) program a part of the change?

Yes, the California Children’s Services (CCS) program is included in the transition to Medi-Cal Rx. Magellan will manage your authorizations and pharmacy claims payment. Your provider and pharmacy will be trained and knowledgeable of the new program.

What should I do if I need a new medication after Saturday, January 1, 2022, and it requires prior authorization (PA)?

Medications that were covered before may or may not be covered by Medi-Cal Rx going forward. Your doctor can submit a PA request to Magellan if needed.  For the first 180 days, no PA request is required for existing prescriptions without previously approved PAs for medications not on the Medi-Cal Contract Drug List. After 180 days, a PA request must be submitted to Magellan. Your doctor has until June 30, 2022 to submit the request.

What should I do if I have a pharmacy service-related complaint after Saturday, January 1, 2022?

Starting Saturday, January 1, 2022, Magellan will handle all pharmacy service complaints. To submit a complaint, please visit www.medi-calrx.dhcs.ca.gov or call Magellan Customer Service toll-free at 1.800.977.2273, 24 hours a day, 7 days a week, 365 days a year.

Please Note: You can only use the Magellan website and toll-free number to file a complaint on or after Saturday, January 1, 2022. Pharmacy complaints through the Alliance will be discontinued on Saturday, January 1, 2022.

How can I appeal a pharmacy benefit decision?

Appeals will be handled through a State Fair Hearing. If you disagree with a denial or change of Medi-Cal Rx services, you may request a State Fair Hearing. The California Department of Social Services has a State Fair Hearing process if you want to appeal a pharmacy benefit decision. This process is different from the appeals process you may have used with the Alliance. In a State Hearing, a judge reviews your request and makes a decision.

If a service is denied or changed, a form to request a State Fair Hearing will automatically be sent to you with the notice of denial or change. You can also get the “State Hearing Request” form at www.dhcs.ca.gov/services/medi-cal/Pages/Medi-CalFairHearing.aspx. Instructions and additional options can be found on the DHCS website.

After Saturday, January 1, 2022, you can also access the State Fair Hearing form by visiting www.medi-calrx.dhcs.ca.gov or by calling Magellan Customer Service toll-free at 1.800.977.2273 (TDD: 711).

You may also call to ask for a State Hearing by calling toll-free at 1.800.952.5253 (TTY: 1.800.952.8349). Please note that the number can be very busy so you may get a message to call back later.

You can get more information about the State Hearing Process by going to www.dhcs.ca.gov/services/medi-cal/pages/medi-calfairhearing.aspx.

Where can I get help finding a pharmacy?

Most pharmacies will accept your new coverage. To ask if your pharmacy will accept Medi-Cal Rx You can call the Medi-Cal Member Toll-Free Help Line at 1.800.541.5555 (TTY 1.800.430.7077).

If you need help finding a pharmacy on or after January 1, 2022, use the Medi-Cal Rx Pharmacy Locator online at www.medi-calrx.dhcs.ca.gov or call Customer Service toll-free at 1.800.977.2273 24 hours a day, 7 days a week, (TTY 711, Monday –Friday, 8 am – 5 pm.

Please Note: The website pharmacy locator will be available in March 2021 and the phone number starting April 1, 2021.

I’m eligible for both Medicare and Medicaid (Medi-Cal). How does this change affect me?

If you are eligible for both Medicare and Medi-Cal, Medi-Cal Rx may cover prescriptions Medicare does not, so you should talk to your doctor or pharmacy if you have any questions.

Who do I contact for help or more information?

For questions about Medi-Cal Rx, please contact DHCS via email at rxcarveout@dhcs.ca.gov. Please make sure to write that you have a question about Medi-Cal Rx. Please do NOT include personal information in your first email. If DHCS staff needs more information to help you, they will reply with a secure email asking for your information.

For more provider resources, please click here.