Update: New and Replacement Medication for Beneficiaries Impacted by the State of Emergency in Additional Regions of the State

Originally Published July 23, 2021
Updated September 8, 2021

On August 30, 2021, Governor Newsom issued an expanded emergency declaration, to include counties affected by the Caldor Fire, McFarland and Monument Fires, Antelope and River Fires, Dixie Fire, Fly and Tamarack Fires and the Lava Fire and Beckwourth Complex Fire. Therefore, the Department of Health Care Services is issuing this update for dispensing, and/or replacing, medication(s) and/or medical supplies to fee-for-service Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) beneficiaries impacted by fires and extreme fire weather conditions or public safety power-shutoff actions. The following guidance is intended to include any and all counties named in the current emergency declaration.

When dispensing the requested medication, pharmacy providers must dispense the full amount immediately if the need to dispense is related to the beneficiary’s displacement or subjection to fires and extreme fire weather conditions or public safety power shutoff, and not have the beneficiary return. Durable Medical Equipment (DME) and medical supply providers must provide requested equipment or supplies immediately or, for items not in stock, as soon as possible.

For fee-for-service Medi-Cal or Family PACT beneficiaries, if the drug/supply being dispensed requires a Treatment Authorization Request (TAR) or Service Authorization Request (SAR), providers are instructed to incorporate the statement “Patient impacted by fires and/or extreme weather conditions or public safety power shutoff” within the miscellaneous information field on the prior authorization request for those drugs or situations requiring a TAR or SAR. The need to create and submit a TAR/SAR should not negatively affect the decision to dispense the full amount of the required medication and/or medical supply immediately and the TAR/SAR can be submitted retrospectively. It is imperative that the impacted beneficiary receive the full amount of the necessary medication/supply in a timely manner to facilitate compliance and to not cause a delay or break in therapy.

TARs/SARs for medications/supplies (new, refill or replacement) will be automatically approved if the TAR/SAR indicates that the beneficiary is impacted by fire, extreme weather or by power shutoffs, and the provider will be paid for the claim for the dispensed medications. The negative impact of the fire, weather event or power shutoff, alone, will meet the criteria of medical necessity.

Providers are encouraged to monitor the Medi-Cal Provider website for future updates. Questions regarding this notice may be directed to the Telephone Service Center (TSC) at 1-800-541-5555, Monday through Friday, except holidays.