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CenCal CareConnect Pharmacy

Welcome to the Pharmacy Information page for CenCal CareConnect (HMO D-SNP). This page provides key information and resources on pharmacy coverage and benefits for CenCal CareConnect members, including Medicare Part D medications and Medicare Part B drugs.

It also includes guidance on Part B drugs administered in the office versus Part D medications obtained through a pharmacy, and how to determine the appropriate benefit.

Part B – Provider-Administered Medications

CenCal CareConnect covers certain medications under the Medicare Part B benefit when they are administered in a physician’s office, clinic, outpatient facility, or home setting. Some of these medications require prior authorization to ensure appropriate and cost-effective use.

Prior Authorization Request Form

Medicare Part B Prior Authorization Drug List

The Medicare Part B Prior Authorization Drug List helps providers quickly identify medications that require prior authorization before administration. The list includes all drugs currently subject to PA requirements along with the clinical policies that apply to each medication.

Part B Prior Authorization Drug List

Utilization Management Clinical Guidelines for Part B Drugs

CenCal CareConnect ensures that all Utilization Management (UM) authorization decisions for our members’ care are based on the medical necessity of the requested health care service. Determinations are made using clinical criteria and guidelines supported by sound, evidence-based medical principles.

CMS Coverage Guidelines

All clinical guidelines applied in Part B UM authorization determinations are based on the following Centers for Medicare & Medicaid Services (CMS) resources, when applicable:

  • National Coverage Determinations (NCDs)
  • Local Coverage Determinations (LCDs)
  • Local Coverage Articles (LCAs)

CenCal CareConnect reviews medical-benefit (Part B) drug requests using the relevant CMS NCD/LCD/LCA guidance when available.

CMS Medicare Coverage Database

MCG Guidelines

CenCal CareConnect uses MCG Guidelines to support the review of product-specific medical necessity for Part B drug requests when appropriate.

MCG Guidelines Access

Medicare Part B Medical Drug Clinical Criteria

When no product-specific policy exists and no applicable CMS NCD, LCD, or LCA governs the request, CenCal CareConnect applies the Medicare Part B Medical Drug Clinical Criteria to guide authorization decisions.

Medicare Part B Medical Drug Clinical Criteria

Part D – Pharmacy Dispensed Medications

Formulary

CenCal CareConnect covers pharmacy-dispensed prescription medications through Medicare Part D. Providers can use the resources below to request coverage determinations and search the current formulary. This includes looking up covered medications, restrictions, and tier information.

Formulary Search Tool Prescription Drug Coverage Determination Form

Prior Authorization (PA) Criteria

Certain medications require prior authorization to confirm they are medically necessary and align with Medicare Part D and Medi-Cal policies. PA criteria help ensure safe, appropriate, and cost-effective use of prescription drugs.

Prescribers may need to submit documentation such as diagnosis, treatment history, and justification for the requested medication.

Prior Authorization Criteria

Step Therapy (ST)

Step therapy may be required for certain medications. Prescribers may need to document that the member has tried one or more preferred alternatives before the requested medication can be approved. This process helps promote safe, clinically appropriate, and cost-effective use of prescription drugs.

Step Therapy Criteria

Frequently Asked Questions

FAQ Accordion

Part B (Medical Services & Drugs): Submit your request using the CenCal Health Prior Authorization Form.
• CenCal Health Prior Authorization Form

Part D (Prescription Drugs): Submit your request using the MedImpact Coverage Determination Form.
• MedImpact Coverage Determination Form

For Medicare Part B and Part D requests, providers must include all relevant clinical documentation that supports medical necessity for the requested medication or service. Required documentation generally includes:

• Diagnosis and ICD‑10 codes

• Relevant clinical history and treatment rationale

• Previous therapies or medications tried and outcomes

• Current medication list and allergies

• Clinical findings supporting the request (e.g., labs, imaging, chart notes, test results)

• Rationale for medical necessity, including why alternatives may not be appropriate

• Any information required by drug‑ or service‑specific coverage criteria (e.g., step therapy, quantity limits, route of administration, setting of care, frequency)

Part B (Medical Services & Drugs):
• Fax: 1-805-681-8262
• Online: Upload through the CenCal Provider Portal
• For Pharmacy Medicare (Part B) Drugs: Fax 1-805-681-8262 or submit via secure link: https://gateway.cencalhealth.org/form/pharmacy

Part D (Prescription Drugs):
• Fax: 1-858-790-7100
• Online: Upload through the MedImpact Provider Portal

Part B (Medical Services & Drugs): Contact the CenCal Pharmacy Prior Authorization team at 1-805-562-1080.

Part D (Prescription Drugs): Contact the MedImpact Prior Authorization team at 1-800-788-2949.

CenCal CareConnect Pharmacy News