MedicaidCoverageHigh impact
23-801 IMPORTANT CLARIFICATION: Physician Administered Drugs Are a Medical Benefit
Health Net·CA·Pharmacy
Effective date
Jan 1, 2022
We identified it
Jun 20, 2026
Summary
Health Net clarifies that Physician Administered Drugs (PADs) like vaccines, chemotherapy, and contraceptives must be covered under the medical benefit, not redirected to Medi-Cal Rx pharmacy benefit. PPGs/IPAs have been incorrectly denying these claims since January 2022 and must reprocess denied claims by August 31, 2023.
Action Required
By August 31, 2023: Billing team must identify and reprocess all PAD claims (vaccines, chemotherapy, anti-rejection drugs, contraceptives, enteral nutrition) that were incorrectly denied to Medi-Cal Rx since January 2022. Update billing procedures to ensure PADs are billed as medical benefit claims, not redirected to pharmacy. Review Division of Financial Responsibility (DOFR) agreements to confirm coverage requirements.