Medical Pharmacy Management

Medical Pharmacy Management

CenCal Health is committed to providing our members with access to high-quality health care. To ensure our members receive quality care, CenCal Health Pharmacy Services has implemented a Medical Pharmacy Management Program to identify utilization management opportunities for Physician-Administered-Drugs billed on a medical and institutional claim. 

Physician-Administered-Drugs (PADs) through CenCal Health's Medical Pharmacy Program include all infused, injectable drugs provided or administered to a member that is billed by a provider on a medical claim by a Procedure Code (i.e. J-Code). These providers include but are not limited to, physician offices, clinics and hospitals. 

Preferred Physician-Administered-Drug (PAD) Program

CenCal Health's Medical Pharmacy Management program includes preferred PADs on the medical benefit. The CenCal Health Preferred PAD Program promotes the use of cost effective equally efficacious drugs when medically appropriate. The program is developed and maintained by a committee comprised of doctors and pharmacist called the Pharmacy and Therapeutics Committee. The committee makes decisions based on information about the drug's safety, effectiveness and associated clinical outcomes.

Preferred Biosimilar Chemotherapeutic Drugs

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:

All affected codes will remain as TAR required, but the preferred biosimilar products must be tried and failed before consideration of coverage of the reference product. 

For further information on Biosimilar products, please see the below references:

If you have questions or need additional information, please contact CenCal Health Pharmacy Department at (805) 562-1080.

Medical Pharmacy Management Policy

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.govThe 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.

Physician-Administered-Drugs (PAD) Authorization Requests

Certain PAD drugs require a prior authorization to ensure medical necessity prior to receiving the drug therapy. Any request for a PAD medication via Procedure Code (i.e. J-Code) requiring a prior authorization administered at a provider's office or infusion/hospital facility, must be submitted as a treatment authorization request (Treatment Authorization Request-TAR). Guidance on how to submit a TAR can be found on CenCal Health's Authorization Page. 

Completing Treatment Authorization Requests (TARs) will help expedite the claims processing. If you do not obtain approval, your claims may be delayed or denied until we receive the information needed to establish medical necessity. 

CenCal Health's Procedures Requiring a TAR tool is available on the CenCal Health website and Provider Portal to search for a PAD TAR requirements.