MedicaidCoverageHigh impact
22-470 Bill Physician-Administered Drugs as a Medical Benefit for Medi-Cal Members
Health Net·CA · Oncology, OB-GYN·Prior Authorization
We identified it
Jun 20, 2026
Summary
Physician-administered drugs (PADs) including chemotherapy, anti-rejection medications, and long-acting contraceptives must be billed as medical benefits on medical claims for Medi-Cal members in Fresno, Kings, and Madera counties. These drugs are NOT billable to Medi-Cal Rx pharmacy benefits except in rare cases with approved prior authorization.
Action Required
Immediately: Billing team must update procedures to bill all physician-administered drugs (chemotherapy, anti-rejection medications, long-acting contraceptives) on medical claims to fee-for-service fiscal intermediary or Plan, NOT to Medi-Cal Rx. Stop directing Medi-Cal members to pharmacies for PADs unless specific prior authorization is approved. Update billing system rules and train staff on proper claim routing to avoid payment delays and denials.