Medi-Cal Rx – Pharmacy Benefit Information for PHC California Members
On January 1, 2022, the Department of Health Care Services (DHCS) will change your pharmacy benefit. Your prescription medications will be covered by “Medi-Cal Rx”. This does not change your Medi-Cal eligibility or benefits.
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.
What is changing?
Starting on January 1, 2022 you will get your Medi-Cal covered prescriptions through Medi-Cal Rx instead of PHC California.
DHCS is working with a new contractor, Magellan Medicaid Administration, Inc. (Magellan) to provide Medi-Cal Rx services.
There will be no change in how you pay for your medications. For most Medi-Cal beneficiaries, there is no cost.
What do I need to do?
PHC California, your doctors and pharmacies know about the changes and know what to do. Because of this, most people in Medi-Cal will not need to do anything.
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 medication?
Most people will not have to change their medications. The list of drugs that require prior approval may be different than the list PHC California uses. Your doctor may need to get approval to refill prescriptions. He or she may talk to you about changing to a medication that does not require prior approval.
Will my pharmacy change?
Most pharmacies will accept your new coverage. You can call the Medi-Cal Member Help Line (1-800-541-5555, TTY 1-800-430-7077) to ask if your pharmacy will accept Medi-Cal Rx.
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 at 1-800-977-2273 twenty-four hours a day, seven days a week or 711 for TTY Monday thru Friday, 8am to 5pm.
Note: The website pharmacy locator will be available in December 2021 and the phone number starting January 1, 2022.
What happens now?
Always bring your PHC California ID card and your Medi-Cal Benefits Identification Card (BIC) with you. Starting January 1, 2022, bring your Medi-Cal BIC card when you go to the pharmacy. The pharmacy will use the card to look up your information and give you your medications.
What if I have questions?
On or Before December 31, 2021
- If you have questions about your medication or other pharmacy services, please call 1-888-436-5018, 24 hours a day, 7 days a week.
- If you have questions about this notice or have Medi-Cal Rx general questions, contact the Medi-Cal Member Help Line (1- 800-541-5555, TTY 1-800-430- 7077), Monday thru Friday, 8am to 5pm.
On or After January 1, 2022
- You can call the Medi-Cal Rx Call Center Line (1-800-977-2273) twenty-four hours a day, seven days a week, or 711 for TTY, Monday thru Friday, 8am to 5pm.
You can also email DHCS at [email protected]. Make sure to write that you have a question about Medi-Cal Rx. Please do NOT include personal information in your first email. DHCS staff will reply with a secure email asking for your information, if they need that information to assist you.
What happens if I have a complaint?
Magellan will accept and resolve your complaint. You can submit a complaint either in writing or by telephone.
- Visit Medi-CalRx.dhcs.ca.gov or
- Call Customer Service at 1-800-977-2273
Note: You can only use this website and phone number to file a complaint on or after January 1, 2022.
Your health plan will no longer handle pharmacy complaints for pharmacy services received on or after January 1, 2022.
How can I appeal a Medi-Cal Rx benefit decision?
The California Department of Social Services has a State Hearing process if you want to appeal a pharmacy benefit decision. This process is different from the appeals process you may have used with your health plan. In a State Hearing, a judge reviews your request with clinical input from DHCS pharmacists to make sure the decision aligns with Medi-Cal pharmacy policy.
If a prescription is denied or changed, a form to request a State Hearing will automatically be sent to you with the notice of denial or change. If you do not agree with a denial or change related to your pharmacy services and benefits under Medi-Cal Rx, you can ask for a State Hearing. You can ask for a State Hearing by sending the State Hearing request form to:
California Department of Social Services State Hearings Division
P.O. Box 944243, MS 19-37
Sacramento, CA 94244-2430
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.
On or after January 1, 2022, you can also get the State Hearing request form by going to www.Medi-CalRx.dhcs.ca.gov or by calling Customer Service at 1-800-977-2273 twenty four hours a day, seven days a week, or 711 for TTY Monday thru Friday, 8am to 5pm.