In March 2022, the California Department of Health Care Services (DHCS) suspended Medi-Cal Rx prior auth requirements to ensure patients maintained timely access to pharmacy benefits. While previous phases of the Medi-Cal Rx transition plan restored prior auth requirements for patients 22 and older, claim edits and prior auth requirements remained suspended for all Medi-Cal Rx covered pharmacy claims for members 21 years of age and younger. Effective January 31, 2025, Medi-Cal Rx will reinstate claim edits and prior authorization requirements for patients 21 years of age and younger on January 31, 2025, as part of a planned "pediatric integration."

As part of this pediatric integration, Medi-Cal Rx will also implement the California Children’s Services (CCS) Panel Authority policy, which will give certain CCS Panel Providers prescribing authority for a limited list of medications and supplies under a set of utilization management policies.

Recognizing the training and experience required by CCS Panel Providers to care for pediatric members with complex medical conditions, the CCS Panel Authority policy will apply to prior auth requests for select drugs, enteral nutrition products and medical supplies. 

In January, Medi-Cal Rx will host weekly webinars about the pediatric integration to support stakeholder readiness.

Additional information and resources will be posted on the “Pediatric Integration” tab in the Medi-Cal Rx Web Portal.