MedicaidCoverageHigh impact
23-803 IMPORTANT CLARIFICATION: Physician Administered Drugs Are a Medical Benefit
Health Net·CA · Oncology, OB-GYN, Family Medicine +6 more·Pharmacy
We identified it
Jun 20, 2026
Summary
PPGs and IPAs have been incorrectly denying Physician Administered Drugs (PADs) since Medi-Cal Rx implementation. PADs given in clinical settings remain a medical benefit under the PPG/IPA's financial responsibility per their Division of Financial Responsibility agreement, not Medi-Cal Rx.
Action Required
By August 31, 2023: Billing team must reprocess all PAD claims that were incorrectly denied to Medi-Cal Rx. Review Division of Financial Responsibility (DOFR) agreements to confirm financial responsibility for PADs administered in clinic, outpatient office, or infusion settings. Stop redirecting PAD claims to Medi-Cal Rx - process as medical benefit claims instead. Contact CalViva Health at 888-893-1569 with questions. Failure to comply may result in contract enforcement and cap deductions.