Medical Pharmacy Management

Medical Pharmacy Benefit

Physician Administered Drug Update

CenCal Health is committed to providing our members with access to high-quality health care.  To ensure our members receive quality care, we will implement updates to the review and approval processes of certain Physician-Administered-Drugs (PADs).

Effective July 1, 2022, CenCal Health now prefers select infliximab biosimilar products over the reference product for adult members.  This determination is consistent with the enabling statue of the Medi-Cal program found in title 22 around the provision of the lowest cost medically necessary service as well as the unanimous adoption by the network physicians and pharmacists at the February 2022 CenCal Health Pharmacy & Therapeutics Committee meeting.

CenCal Health’s preferred biosimilars are for the following physician administered drug:

As part of the Preferred Physician-Administered Drug Program, CenCal Health will prefer select biosimilar chemotherapeutic products over their reference products.  The biosimilar products are not interchangeable with the reference product, and will require new orders. Biosimilar products are highly similar, and have no clinically meaningful differences from an existing FDA-approved reference product.

CenCal Health currently prefers the following biosimilar products over their reference product:

Medical Pharmacy Management Criteria

Medical Pharmacy Management Criteria is defined as clinical criteria utilized to review authorization requests for authorization of pharmaceuticals (i.e. Physician Administered Drugs) requested on CenCal Health’s medical benefit.  The authorizations rendered on the medical benefit are ultimately associated with claim adjudication on a medical, institutional claim on CenCal Health’s Medical Benefit.

CenCal Health utilizes the Magellan Rx Management Library of Medical Necessity Guidelines, Medi-Cal Provider Manual, and the Manual of Criteria for Medi-Cal Authorization for review of pharmaceuticals on the Medical Benefit.  The criteria is utilized in determining whether a requested pharmaceutical is medically necessary. Services determined to be experimental, investigational, unproven, or not medically necessary by the clinical evidence are typically not covered.

Magellan Rx Management is committed to the pursuit of clinical excellence and full transparency, using the most clinically sound resources available to guide in the development of guidelines, algorithms, and criteria for medical treatment. Sources used in development and adoption of guidelines and algorithms are derived from multiple sources: FDA labeling, pivotal clinical trials, CMS-approved compendia (NCCN, Clinical Pharmacology, LexiComp Lexi-Drugs, Micromedex DrugDex, AHFS-DI), evidence-based clinical practice guidelines, published peer-reviewed literature, and input from key opinion leaders.

The Medi-Cal Provider Manual contains information on Medi-Cal services, programs, and claim reimbursement.  The manuals are available in their entirety, free of charge, on the Internet at www.medi-cal.ca.gov.The Manual of Criteria for Med-Cal Authorization has established regulations governing the Medi-Cal program, which require that certain services can be authorized and paid only after appropriate professional review by a physician, registered nurse, or pharmacist consultant.  The review criteria published in this manual, while not exhausting the range of services covered by Medi-Cal, assists in standardizing professional judgement.  The criteria themselves have been developed by medical professionals and are to be used as guidelines. The manual is incorporated, by reference, into the state regulations.

Medical Pharmacy Management clinical criteria sets are adopted and maintained by a committee comprised of network doctors and pharmacists called the Pharmacy and Therapeutics Committee. Our Medical Benefit Drug Criteria express our determination of whether a medication is proven to be effective based on the published clinical evidence.

If you have any questions or need additional information on the Medical Benefit Pharmacy Criteria, please contact CenCal Health Pharmacy Department at (805) 562-1080.