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 reinstated claim edits and prior authorization requirements on new start prescriptions for patients 21 years of age and younger on January 31, 2025, as part of a planned "pediatric integration." While DHCS initially announced the reinstatement would apply to ALL pediatric prescriptions, they subsequently decided it would only apply to new start drugs and products at this time. Continuation of therapy claims will not  be subject to prior authorization requirements for a period of at least 60 days, but will be subject to all other utilization management claim edits.

As part of this pediatric integration, Medi-Cal Rx also implemented the California Children’s Services (CCS) Panel Authority policy, which gives 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. 

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